Urology Coding Alert

Reader Question:

Express Prostate Massage

Question: One of the physicians in my practice does express prostate massage. When I asked the physician to describe this procedure to me, he explained: A urine sample is taken beforehand. Next, the prostate is massaged and milked through the perineum. Another urine sample is taken. The urine containing expressed prostate secretions is reviewed under a microscope by the physician, then the specimen is sent to an outside lab for culture and specificity. According to the physician, this is done in patients with a diagnosis of prostatitis to determine whether the inflammation is bacterial, non-bacterial, or whether the patient simply has prostatodynia. How should I code this? Would this be billable in addition to an evaluation and management (E/M) visit code, or would it be considered inclusive?

Anonymous Kansas Subscriber

Answer: There is no separate CPT code for express prostate massage. This procedure should be considered inclusive of the E/M visit code. The microscopic exam of the urine by the physician could be separately coded with 81015 (urinalysis; microscopic only).
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in Revenue Cycle Insider
  • 6 annual AAPC-approved CEUs
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more

Other Articles in this issue of

Urology Coding Alert

View All

Which Codify by AAPC tool is right for you?

Call 844-334-2816 to speak with a Codify by AAPC specialist now.