Urology Coding Alert
Report Prostate Nodules Based on Diagnosis, Procedure and Carrier Requirements
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 Laura Siniscalchi, RHIA, CPC, CCS-P, CCS, senior consultant with the Boston office of the auditing firm Deloitte and Touche. "Communication with the physician will help pinpoint what is meant."
Another option is to see if the patient has an elevated PSA, says Cynthia Jackson, RRA, CPC, an independent coding specialist based in Lawrenceville, Ga. "If I saw 'prostate nodule' and no other documentation, I would use 600.1."
Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services of Denver, notes that it is the physician's responsibility to indicate the most accurate diagnosis and to make sure that the words in the chart will be understood. If the notes are unclear, the coder should ask the physician for clarification. "Ask the physician what he means by prostate nodule," Page says.
Ultrasound (76872)
A urologist might order a TRUS to view the prostate after detecting a nodule on rectal examination. Carriers generally consider a TRUS without biopsy a screening, which is not covered by Medicare. The biopsy must be guided ultrasonically so some carriers will pay for only one ultrasound under certain circumstances. But the urologist may perform a TRUS to see if a biopsy is warranted; this ultrasound is the hardest to be ethically reimbursed for.
To bill Medicare for TRUS with needle biopsy when performed by the same physician, report 76942 and 55700. When performed with a radiologist, the urologist bills 55700 and the radiologist reports 76942. If, however, the patient has a diagnostic ultrasound, which is immediately followed by needle biopsy, use 76872, 76942 and 55700. Do not bill separately for ultrasonic guidance at the time of radioactive-seed implantation.
Carriers often have their own rules for medical necessity, including allowable diagnosis codes and, sometimes, more requirements and limitations.
LMRP Examples
Local medical review policies (LMRPs) differ on accepted diagnoses for prostate nodules and ultrasounds:
Trailblazer allows no exceptions: "Diagnosis(es) must be present on any claim submitted, and must be coded to the highest level of specificity." Also, "The diagnosis code(s) must be representative of the patient's condition." Despite the verbiage on not using TRUS for screening, the medical-necessity list includes benign prostate diagnoses. Also, 239.5, which clinicians feel is the most appropriate diagnosis code for a prostate nodule that might require a biopsy, is not on the list. Coders should include documentation on the reason for TRUS for claims with benign diagnosis and contact the carrier when considering using 239.5.
Note: When repeat biopsies are performed on a nodule of uncertain behavior, bill 55700 and 76942 only with 236.5. Repeat TRUS are not usually needed in follow- up and most likely will not be paid.
PSA
PSA (84153 or 84154) is often performed to evaluate a suspicious prostatic nodule. Medicare covers screening DRE (G0102) and PSA (G0103).
Two examples demonstrate carrier variation on medical necessity for PSA testing:
Follow Your LMRP
Although many carriers will reimburse for a TRUS with a diagnosis of BPH or BPH-nodule, they will not pay for a screening. Physicians should know how their carriers prefer filing these claims, Jackson says: "They need to be aware of what their Medicare carrier allows."
In addition to checking the current LMRP, keep track of bulletins and newsletters from carriers, which update coding information.
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