Urology Coding Alert

Question: My urologist performed a transrectal ultrasound guided aspiration of a pelvic mass and a radical perineal prostatectomy for a patient with history of prostate cancer. The urologist aspirated 120 ml. of fluid and the pathology came back as "acute inflammation with histiocytes and sperm." Both the culture and gram stain were negative. I think I should report 76872, 76942 and some other code, but I am not sure. Can you tell me if I am on the right track?

Florida Subscriber

Answer: Since the patient's prostate was previously removed, you should use the following coding for your scenario.

First, report 10160 (Puncture aspiration of abscess, hematoma, bulla or cyst) for the aspiration of the cyst- ic mass.

Then, use 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) for the ultrasonic guidance. Attach modifier 26 (Professional component) if your urologist performed the procedure in a facility such as a hospital or ASC.

Finally, report 76856 (Ultrasound, pelvic [nonobstetric], real time with image documentation; complete) if the urologist performed a pelvic sonogram without prostatic sonography. Again, append modifier 26 if necessary.

Tip: The urologist should mention the surgically absent prostate gland in his documentation.