Urology Coding Alert

Regardless of where the prostate biopsies are performed and whether a radiologist is present, you will always need to report code 55700 for your urologist's service. Code 55700 represents the biopsy procedure itself, in which the radiologist usually takes no part. But three different scenarios will affect how and when you should report codes 76942 and 76872.

1. Facility setting with the radiologist present. If a urologist performs a prostate biopsy with ultrasonic guidance and a transrectal echography in the hospital or other facility setting, we can assume the hospital owns the radiology equipment. Let's also assume that there is a radiologist in the room supervising the radiology procedures during the prostate biopsy and documenting an interpretation and report of the findings. Because the urologist is only performing the biopsy and is not supervising and interpreting the ultrasonic guidance and transrectal echography, 76942 and 76872, the urologist can only report 55700. The hospital will report both the technical and professional components of the radiology services for the radiologist who was present.

Now let's assume the urologist performs a prostate biopsy with ultrasonic guidance and a transrectal echography in the hospital setting (he doesn't own the equipment) and there is no radiologist present during the surgical session. The urologist not only documents taking the biopsy but documents two radiology reports, one for the ultrasonic guidance and another for the transrectal echography. The urologist's services should be coded 55700, 76942-26 (Professional component) and 76872-26.

Modifier -26 is used to indicate that a physician only read and interpreted a test without owning the equipment, says Joyce Dansby, CPC, office manager for A&R Management in Tampa, Fla. You can determine whether a code has both a professional and a technical component by checking whether it is listed twice in the Medicare Physician Fee Schedule Database (MPFSD), she adds.

Local modifiers such as modifier -ZP, which was introduced in New York no longer need to be attached to the ultrasonic procedures to indicate professional services.

When a urologist performs both a surgical service and a radiology service in his office without the presence of a radiologist, he can report both the surgical CPT code(s) and the radiology CPTcode(s) without appending any modifiers. Reporting both the technical and professional components is considered reporting the "global" code, Dansby says. The urologist can report the full radiology service because he owns the equipment and supervises and interprets the services, she says. So if a urologist alone performs a prostate biopsy with ultrasonic guidance and a transrectal echography, you should report 55700, 76942 and 76872.

Medicare and many private carriers reimburse the urologist for his performances of the biopsy and the two ultrasonic procedures. However, some private carriers will pay for the biopsy and only one sonographic procedure, bundling the two. Appeals with documentation and an approval letter from the American Urological Association have been only moderately successful in reversing a carrier's decision to pay for only one ultrasonic service, experts say.