Urology Coding Alert

Question: How would I report the procedure described in this operative report? There is also an accompanying radiology report describing stereotactic guidance imaging performed prior to the procedure that my urologist used to determine planar position beforehand to make sure they only sampled prostate material. Would this be 55706 or 55700 with 76872-26?

Diagnosis: Elevated PSA, history of prostate cancer

Procedure: Transperineal prostate precision point biopsy

Anesthesia: Monitored anesthesia care

Indications: Patient has a PSA of 24.40, nodular prostate. Patient presents for a transperineal precision point prostate biopsy.

Description of procedure: Patient was given 2 g of IV Ancef. Transrectal ultrasound was performed in the dorsolithotomy position after sterile prep and scrotal retraction. This showed the prostate measured 40.31 g. Was markedly abnormal with hypoechoic region and mixed echogenicity. Capsule was symmetrical; however, seminal vesicles were symmetrical. 1% lidocaine was used to provide prostatic block bilaterally through the precision point needle attachment. Right posterior and base areas were biopsied first via the transperineal access needle placed in appropriate position. Then biopsied the right anterior medial, anterior lateral after moving the needle to second from the top. I then biopsied the left anterior and medial and lateral positions. The left posterior medial and lateral and base was the biopsied in similar fashion with appropriate needle placement. A total of 20 cores were obtained. Patient tolerated procedure well, estimated blood loss was 5 mL, no complications.

Complications: None

Operative findings: 40.31 g prostate with significant hypoechoic cortical regions in the midline and right base mid area with areas of mixed echogenicity throughout. Capsule was symmetrical and intact as were seminal vesicles and some transitional zone hypertrophy noted.

Wisconsin Subscriber

Answer: You should report 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach) for this procedure. You’ll use 55700 for any prostate biopsy, whether the urologist obtains the cores by a perineal, transrectal, or endoscopic approach, unless the urologist performs the specific work described in the code descriptors for 55705 (Biopsy, prostate; incisional, any approach) or 55706 (Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance).

Urologists can perform the procedure described in 55700 with or without imaging guidance, such as ultrasound or magnetic resonance imaging (MRI), and you can separately report the imaging guidance if performed. Most often, you’ll report 55700 with 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation). If performed in a facility setting, append modifier 26 (Professional component) to 76942 since the facility owns the equipment and you’re billing for the physician’s interpretation work.

Key: Report 55700 once per session no matter how many cores your urologist obtains. The code description doesn’t specify an no upper limit for the number of cores taken, which means you wouldn’t report 55700 more than once.

Code 55706 (Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance) does not accurately describe the biopsy procedure in this operative report. A true saturation biopsy is a very involved procedure with specific indications and defined steps that must be performed, as follows:

• Patient has a prior suspicious biopsy or a prior negative biopsy with rising prostate specific antigen (PSA).
• The procedure is performed in an operating room under general or spinal anesthesia.
• A template grid is used to map the (entire) prostate gland. This grid enables the physician to remove cores at 5 mm intervals using a stereotactic approach.
• Cores are taken at 5 mm intervals and each specimen is labeled to correspond to the location of each core chosen. In deeper planes, both a proximal and distal biopsy may be obtained.
• Each biopsy sample is marked for its coordinates, and all are mapped in 3D to determine the extent and exact position of malignant cells.

Typically, 35-60 biopsies are taken, based upon the size of the gland.

Additionally: Code 76872 (Ultrasound, transrectal) would not be appropriate because the imaging was not diagnostic to confirm the nodular prostate, but rather for guidance.