Urology Coding Alert

Question: Our Medicare carrier does not pay for prostate biopsies and ultrasounds with a diagnosis of 239.5. Which code is correct with an abnormal prostate? Also, another carrier does not reimburse for prostate biopsies with a diagnosis code of 790.93. Which code is correct when the digital exam is normal, yet the patient has an elevated prostate specific antigen (PSA) indicating biopsy?

Maine Subscriber

Answer: First of all, most Medicare carriers do pay with a diagnosis of 239.5 (neoplasm of unspecified nature, other genitourinary organs). In any event, you should not wait for a pathology report before submitting the claim (except in the case of certain skin lesions). If the patient had an elevated PSA, then you also would code 790.93 (elevated prostate specific antigen). Code V10.46 would be used if there is a personal history of prostate cancer, while V16.42 indicates a family history of prostate cancer.

Submitting any and all secondary diagnoses with your claim will help reimbursement.

Always check the diagnosis codes in the ICD-9 manual and never code from the index. Also, always look further if you think there might be a code to better describe the findings. And remember, code for the reason the procedure was performed, not for the pathology.

Part B: Usually, pathology is very specific about its findings. If nothing is found in the pathology, then file a dispute with your carrier because an elevated PSA is an indicator for the biopsy.

Note: This highlights the importance of checking with the Medicare carriers local medical review policy and the carriers coding guidelines because ultimately the payers guidelines govern how the claim will be processed.