Wiki 55706

[neecen]

We have a coder telling our provider that he can't bill 55706 unless he includes 3D mapping in his documentation. Based on the information below, using 55706 is already indicating the biopsy sample is mapped in 3D. I can't find any clear guidelines that state yes 3D mapping needs to be documented or no 3D mapping does not need to be documented. Any help is appreciated!

TIA

Denise


55706: Biopsies, prostate, needle, transperineal, stereotactic template-guided saturation sampling, including imaging guidance. CPT code 55706 is used for the performance of a “saturation” biopsy. A true saturation biopsy is a unique procedure that is performed in specific indications and following the steps as defined by the American Medical Association (the owner of the CPT copyright):

• The patient has a prior suspicious biopsy, or a prior negative biopsy [result] with rising PSA [prostate-specific antigen].

• The procedure is performed in an operating room under general or spinal anesthesia.

• A template grid to map the (entire) prostate gland is used. 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 with 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 to 60 biopsies are taken, based on the size of the gland.

CPT code 55706 should not be performed in the office setting, as there are no practice expense inputs to reimburse for supplies, clinical staff, or equipment. This is a 10-day global procedure, and imaging guidance is included so imaging cannot be billed separately.

 

[sls314]

We have a coder telling our provider that he can't bill 55706 unless he includes 3D mapping in his documentation. Based on the information below, using 55706 is already indicating the biopsy sample is mapped in 3D. I can't find any clear guidelines that state yes 3D mapping needs to be documented or no 3D mapping does not need to be documented. Any help is appreciated!

TIA

Denise


55706: Biopsies, prostate, needle, transperineal, stereotactic template-guided saturation sampling, including imaging guidance. CPT code 55706 is used for the performance of a “saturation” biopsy. A true saturation biopsy is a unique procedure that is performed in specific indications and following the steps as defined by the American Medical Association (the owner of the CPT copyright):

• The patient has a prior suspicious biopsy, or a prior negative biopsy [result] with rising PSA [prostate-specific antigen].

• The procedure is performed in an operating room under general or spinal anesthesia.

• A template grid to map the (entire) prostate gland is used. 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 with 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 to 60 biopsies are taken, based on the size of the gland.

CPT code 55706 should not be performed in the office setting, as there are no practice expense inputs to reimburse for supplies, clinical staff, or equipment. This is a 10-day global procedure, and imaging guidance is included so imaging cannot be billed separately.

The documentation has to accurately reflect what was performed.

Just because something is in the definition of the code doesn't mean that the physician actually performed that service for that patient. You can only code what is supported by the documentation.

The coding and compliance mantra: "If it isn't documented, it didn't happen."

Edit to add: This is a general answer, because I haven't read the specific documentation for this patient of course. But if the code says that all steps must be performed to have the service be a saturation biopsy, then that means that all the steps should be documented too. Always good to be complete and thorough so that you can defend the note in case of an audit.

 

[neecen]

The documentation has to accurately reflect what was performed.

Just because something is in the definition of the code doesn't mean that the physician actually performed that service for that patient. You can only code what is supported by the documentation.

The coding and compliance mantra: "If it isn't documented, it didn't happen."

Edit to add: This is a general answer, because I haven't read the specific documentation for this patient of course. But if the code says that all steps must be performed to have the service be a saturation biopsy, then that means that all the steps should be documented too. Always good to be complete and thorough so that you can defend the note in case of an audit.

Thanks Susan. This all makes perfect sense to me. I just wish there was somewhere in writing that states this must be in the documentation as we are trying to convince a, for lack of better term, hardheaded provider!