Urology Coding Alert

Reader Questions:

Decode This Prostate Biopsy Puzzle

Published on Fri Aug 11, 2023

Question: Can 76872 or 76942 be billed with 55700 for the following procedure? I think there was an interpretation, but I didn’t find a saved image in the record:

Procedure: Prostate biopsies 12 core templated systematic biopsies PIRAD 4 lesions left medial. Indications: The patient presents with an elevated PSA. He has had both an elevated 4K score at 64 as well as an MRI showing a PI-RADS 4 lesion along the left mid medial border. Description of the procedure: The patient was placed into the lateral position. An ultrasound probe was advanced per the patient’s rectum and the prostate examined. There was a hypoechoic spot corresponding to the demarcated PI-RADS 4 lesion. Seminal vesicles were normal. Prostate was diffusely enlarged with a volumetric analysis of 49 g. No bulging of the capsule. Using the BK MRI fusion system, the previously identified lesion(s) were identified and targeted and targeted biopsies taken. Additional prostate biopsies were then taken from the right and left sides in a systematic fashion. There was no significant bleeding. The procedure was well-tolerated without any complications.

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Answer: For this scenario, you may report 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation) since there is not a separate report for the finding of the transrectal ultrasound (US) and no image was retained in the medical record to support 76872 (Ultrasound, transrectal). You would also report transrectal US if there is a separate diagnostic report with a saved US image of the prostate.

This must be a separate interpretation of the findings. Some commercial health plans will allow reporting both 76872 and 76942 ultrasonic guidance if the documentation can support the use of both codes.

The appropriate code for the perineal biopsy would be 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach). This code would be used for any technique of prostate biopsy, including perineal biopsy, no matter how many cores are taken and even if using a stepper or grid.

During your research and coding of the procedure, you may find code 55706 (Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance) to be a plausible solution. It would be improper to bill 55706 because a true saturation biopsy is a unique procedure that is performed in an operating room under anesthesia, not in an office setting. According to the AMA, the following criteria must be met to use 55706:

The patient has a prior suspicious biopsy, or a prior negative biopsy result with rising Prostate Specific Antigen (PSA).
The procedure is performed in an operating room under general or spinal anesthesia.
The urologist uses a template grid to map the entire prostate gland. This grid enables the physician to remove cores at 5 mm intervals using a stereotactic approach.
Cores are taken at 5 mm intervals, and each specimen is labeled to correspond with the location of each core chosen. In deeper planes, both a proximal and distal biopsy may be obtained.
Each biopsy sample is marked for its coordinates, and all are mapped in 3D to determine the extent and exact position of malignant cells.
Typically, 35-60 biopsies are taken based on the size of the gland.

This is a 10-day global procedure, and imaging guidance is included so imaging cannot be billed separately.

Remember: “There was a lot of controversy when 55706 was developed and approved by the AMA for use on Jan. 1, 2009. As stated above, there are very specific requirements for reporting 55706. If these requirements are not met, 55700 should be used to report prostate biopsies,” said Stephanie Stinchcomb Storck, CPC, CPMA, CUC, CCS-P, ACS-UR, longtime urology coder and consultant in Glen Burnie, Maryland.