Urology Coding Alert

When a urologist palpates a nodule to determine if it is benign, he or she may order transrectal ultrasound (TRUS) (76872), biopsy (55700), the associated ultrasound (76942) and prostate-specific antigen tests (84153, 84154). Only 236.5 and 239.5 tell the payer the test was ordered because the urologist did not know the cause of the lesion. But few insurers will pay for a TRUS on 236.5 or 239.5 only. They want a biopsy also.
 
Note: 76872 Echography, transrectal; 55700 Biopsy, prostate; needle or punch, single or multiple, any approach; 76942 Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation; 84153 Prostate-specific antigen [PSA]; total; 84154 free; 236.5 Neoplasm of uncertain behavior of genitourinary organs; prostate; 239.5 Neoplasms of unspecified nature; other genitourinary organs.
 
Some carriers will pay for all three prostate diagnostic procedures 76872, 55700 and 76942 on the same day with 236.5 or 239.5. Most carriers will deny payment for a TRUS with only 239.5, but they will pay for the biopsy and the ultrasonic guidance. Some will pay for the TRUS with 600.1 (Hyperplasia of prostate; nodular prostate).
 
Choosing the Diagnosis Code
A chart note may say a patient has an "enlarged prostate" that is associated with "BPH" even though benign prostatic hyperplasia (BPH) is a histological diagnosis. "But BPH has been so used in the jargon of urology that instead of saying a patient has an enlarged prostate, many urologists will say the patient has BPH," says Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York, Stony Brook. Code 600.0 (Hypertrophy [benign] of prostate) is not for a nodule or a nodular prostate, but BPH can be associated with nodules.
 
"Code 239.5 is probably the most appropriate diagnosis to use in evaluation of an undiagnosed prostatic nodule," Ferragamo explains. "This represents the clinical circumstances of a prostatic nodule requiring a biopsy." However, this is not the best code to use for a TRUS alone, because carriers omit it on medical-necessity lists for 76872.
 
When "prostate nodule" is documented, do not use 600.1 if a suspicion of a malignant process exists, Ferragamo says. If the notes contain a diagnosis of "nodule of the prostate," which the physician evaluated, often with PSA and ultrasonically guided biopsy, use 236.5 or 239.5 based on what the carrier accepts, he recommends.
 
If the physician indicates a nodule of the prostate that is not suspicious for carcinoma and is associated with BPH, use 600.1, Ferragamo says.
 
It's easy to see how a coder could make the mistake of using 600.1 when the notes say "prostate nodule." Any search of nodular prostate or prostate nodule in ICD-9 will yield 600.1. "That's the right code for a prostate nodule," says [...]