Urology Coding Alert

How would you report this procedure?

Test your operative report interpretation skills with this case study from a Urology Coding Alert subscriber in New York.

I have a case where I'm having trouble assigning the CPT Codes . Here is the operative report:

Nature of Operation: Transrectal ultrasound-guided biopsy of perivesical mass/periurethral tissues

Indication: Patient has a history of prior radical prostatectomy with lymph node dissection. Endorectal MRI of the pelvis identifies tissue bilaterally along the region of the neurovascular bundles particularly on the right side which appears suspicious. Biopsy of these areas was recommender prior to initiation of radiotherapy.

Operative Procedure: Following sedation, the patient was placed in modified dorsal lithotomy position. Bimanual examination was performed. Fibrotic area was noted along the right and left side. More so, on the right in the region of neurovascular bundle, but no evidence of palpable tumor was appreciated.

Transrectal ultrasonography was then performed identifying tissue in these regions that was hyperechoic. No evidence of retained seminal vesicles was seen radiographically. Biopsy was performed on both right and left sides extensively from the very base of the bladder up to the apex. Multiple cores were obtained and all of these were sent to pathology for permanent section. Periurethral biopsies were also obtained from left and right side. These tissues were sent to pathology as separate specimens. Mild bleeding was noted from the rectum and light hematuria was appreciated.

Specimens submitted to pathology: Right and left base perivesical tissue, right perivesical tissue, right and left periurethral tissue, midline posterior urethral biopsy.

Pathology results: Benign fibromuscular tissue with focal multinucleated giant cell reaction. Benign colonic mucosa.

How would you code this procedure?

Answer: You should report the following codes for this case:

• Report 20206 (Biopsy, muscle, percutaneous needle) for the needle biopsy of muscular tissue around the prostate
• Report 76942 (Ultrasonic guidance for needle placement [eg, biopsy, aspiration, injection, localization device], imaging supervision and interpretation) for the ultrasonic guidance
• Use diagnosis code 239.2 (Neoplasm of unspecified nature of bone soft tissue and skin) for the pathology-pending soft tissue biopsy. (When you start using ICD-10 in 2013, the diagnosis code you will use is D49.2, Neoplasm of unspecified behavior of bone, soft tissue, and skin.)

Bonus: Want your complicated operative report featured in Code This!? Send it to Leesa at leesai@codinginstitute.com.