Urology Coding Alert

Question: A patient had a transrectal ultrasound (US) that resulted in ultrasound-guided biopsies of the left and right lobe of the prostate. Next, the surgeon went on to perform a transurethral resection of the anterior wall of the bladder. What’s the CPT^® coding?

Indiana Subscriber

Answer: With documentation of a transurethral resection of the bladder, you know you will be working with the appropriate cystourethroscopy code. In this example, you have a cystourethroscopy with resection of a bladder tumor, which leads to the following options:

• 52234 (Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm))
• 52235 (… MEDIUM bladder tumor(s) (2.0 to 5.0 cm))
• 52240 (… LARGE bladder tumor(s))

So long as the provider is fluent with the measurements needed to report each respective code, you can consider references to small, medium, or large tumors sufficient to meet the criteria for code reporting. However, it’s in the provider’s best interest to be specific with tumor dimensions to avoid any confusion.

Next, you’ll code for the US-guided biopsy. In reporting the correct biopsy code, 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach), make sure to find documentation that supports a needle or punch biopsy. This can include documentation as simple as “core needle” or “biopsy core” — which are terms referencing a core needle biopsy.

The last part of the equation involves selecting one or more codes to report the transrectal US and subsequent US guidance. However, you must keep in mind that the answer to this question may depend on payer. For Medicare (and most commercial carriers), you should consider code 76872 (Ultrasound, transrectal) inclusive of both the underlying transrectal US and subsequent guidance for placement of the needle during biopsy. In these instances, you will exclusively report code 76872.

To consider: In rare circumstances, some commercial payers may allow you to report 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation) alongside 76872 with a modifier 59 (Distinct procedural service) appended to 76942. While these two codes reveal a National Correct Coding Initiative (NCCI) modifier indicator of “1,” you may justify the coding of both services by explaining that the initial transrectal US is utilized to scan the prostate for any underlying pathology prior to the biopsy. Check with the specific carrier as to how to bill for the ultrasound services.