Urology Coding Alert

Question: When doing a prostate biopsy, my physician always performs 12 biopsies. The codes I use are 76872, 76942, 55700, CPT 96372-59, and J1580. Is there any way to get reimbursed for all 12 of the biopsies? Medicare will not even pay the 55700 at all if I bill with 12 units although some of the other payers have paid me. What is the correct way to bill for multiple prostate biopsies?

Rhode Island Subscriber

Answer: Code 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach) includes single or multiple needle biopsies of the prostate gland. To try to bill 55700 multiple times or with multiple units is incorrect coding.

Audit proof: Recently following a payer's intense audit a large urological group was required to refund a significant amount of revenue and fines for inappropriate use of 55700, when the carrier discovered that the urology group had billed and coded multiple times (12) for multiple biopsies of the prostate gland performed on individual patients. This multiple coding of 55700 had erroneously been claimed and submitted for many patients undergoing prostate biopsies by this group. Because of the actual CPT manual description of 55700 and the recent audit and findings of a non-Medicare large national payer, you should follow 55700 guidelines and report the code only once no matter how many biopsies are obtained at a single encounter.

Keep in mind: The Correct Coding Initiative bundles 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) into 55700. Although the bundle has a modifier indicator of "1,"meaning this edit can be broken with a modifier, in this clinical scenario you should not report 96372 with the biopsy. There are no clear indications for use of modifier 59 (Distinct procedural service) under the described circumstances.  Answers to Reader Questions and You Be the Coder

contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, University Hospital, State University of New York, Stony Brook.