Good Morning,
We are having a discussion in our office regarding proper coding for a Tuna with Trus. Some say that the TRUS is separately billable some say not. I cannot find clear guidelines regarding this, one way or the other. The provider billed 53852 + 76872 - both performed in his office.
I am hoping someone can help guide us.
In the op note, the provider states that the patient was brought into the procedure room, and he discussed the nature of the illness, nature of the procedure, its intended risks benefits etc.. Patient arrived one hour prior to the treatment time and took 1 Percocet 5/325 and 1 Valium 10 mg. It was confirmed that the antibiotic and enema were taken as prescribed. He was place in the lateral decubitus position and Amikacin 500 mg was given IM. Transrectal US was performed (see separate report) and periprostatic block was given with 20 cc's of 1% lidocaine w/o epi. the transverse measurement was 5.27 cm. In addition 10 cc's of 1% lidocaine jelly was administered into the urethra and a penile clamp applied. He was brought into the procedure room, the return electrode was placed on the lower back, and he was properly positioned on the Sonesta chair. A time out was called correctly identifying the patient using 2 patient identifiers. the procedure, the site and use of pre op antibiotics were all discussed and agreed upon. The Hand Piece place on a sterile field and the tubing system was connected to a 1 liter bag of sterile water. Using the Prostiva needle ablation technique the prostate was treated at the median lobe and the lateral lobes. The median lobe was treated w 12 mm needle length 1 cm from the bladder neck and the lateral lobes with an 20 mm needle length. Each lateral lobe was treated at 1 cm interval from the bladder neck toward the veru. The last treatment was 1 cm from the veru. Each lesion had rapid rise temperature to 115 degrees celsius and was maintained throughout the entire 2 min and 20 sec treatment time. A total of 3 treatments were given. The patient tolerated the treatment well. A #16 french foley was placed and connected to a leg bag and slightly blood tinged urine was noted. Post procedure instructions and precautions were given, including how and when to remove the foley. Follow up appointment was given.
The TRUS note = The patient was positioned in the left lateral decubitus position and the prostate was imaged in the tranverse and sagital plane. The seminal vesicles were equal and symmetrical and the capsule was intact. The prostate measured 4.96 cm W x 5.18 cm H x5 cm L totaling 67.1 grams. There were no hypoechoic areas. Patient tolerated the procedure well. Post procedure instructions, precautions, and a follow up appointment was given.
I appreciate any guidance provided.
Thank you
Kathleen
We are having a discussion in our office regarding proper coding for a Tuna with Trus. Some say that the TRUS is separately billable some say not. I cannot find clear guidelines regarding this, one way or the other. The provider billed 53852 + 76872 - both performed in his office.
I am hoping someone can help guide us.
In the op note, the provider states that the patient was brought into the procedure room, and he discussed the nature of the illness, nature of the procedure, its intended risks benefits etc.. Patient arrived one hour prior to the treatment time and took 1 Percocet 5/325 and 1 Valium 10 mg. It was confirmed that the antibiotic and enema were taken as prescribed. He was place in the lateral decubitus position and Amikacin 500 mg was given IM. Transrectal US was performed (see separate report) and periprostatic block was given with 20 cc's of 1% lidocaine w/o epi. the transverse measurement was 5.27 cm. In addition 10 cc's of 1% lidocaine jelly was administered into the urethra and a penile clamp applied. He was brought into the procedure room, the return electrode was placed on the lower back, and he was properly positioned on the Sonesta chair. A time out was called correctly identifying the patient using 2 patient identifiers. the procedure, the site and use of pre op antibiotics were all discussed and agreed upon. The Hand Piece place on a sterile field and the tubing system was connected to a 1 liter bag of sterile water. Using the Prostiva needle ablation technique the prostate was treated at the median lobe and the lateral lobes. The median lobe was treated w 12 mm needle length 1 cm from the bladder neck and the lateral lobes with an 20 mm needle length. Each lateral lobe was treated at 1 cm interval from the bladder neck toward the veru. The last treatment was 1 cm from the veru. Each lesion had rapid rise temperature to 115 degrees celsius and was maintained throughout the entire 2 min and 20 sec treatment time. A total of 3 treatments were given. The patient tolerated the treatment well. A #16 french foley was placed and connected to a leg bag and slightly blood tinged urine was noted. Post procedure instructions and precautions were given, including how and when to remove the foley. Follow up appointment was given.
The TRUS note = The patient was positioned in the left lateral decubitus position and the prostate was imaged in the tranverse and sagital plane. The seminal vesicles were equal and symmetrical and the capsule was intact. The prostate measured 4.96 cm W x 5.18 cm H x5 cm L totaling 67.1 grams. There were no hypoechoic areas. Patient tolerated the procedure well. Post procedure instructions, precautions, and a follow up appointment was given.
I appreciate any guidance provided.
Thank you
Kathleen