Urology Coding Alert

A diagnosis of testicular cancer is usually made clinically because the tumor feels hard and certain tumor markers are elevated. An orchiectomy is performed based on this clinical judgment. But when a urologist only suspects testicular cancer, he or she must proceed carefully in biopsying the tumor to avoid "seeding" or spreading the cancer cells. For this reason, a biopsy is performed during a surgical session, which may proceed to a total orchiectomy if the biopsy is positive. The coding dilemma lies in how to bill for the surgical work if the biopsy is negative and no orchiectomy is performed.
Orchiectomy after Biopsy
A urologist who diagnoses testicular cancer preoperatively by clinical examination, sonography (76870, Ultrasound, scrotum and contents), and testicular markers (blood test) proceeds to surgery without a biopsy, removing the testicle using an inguinal approach and billing CPT 54530 (Orchiectomy, radical, for tumor; inguinal approach). On the rare occasions that this procedure is performed bilaterally, bill 54530 with modifier -50 (Bilateral procedure).
 
If the urologist questions whether a malignant tumor exists, he or she makes an inguinal incision, frees and partially clamps the spermatic cord, brings the testicle up out of the scrotum, carefully packs the surrounding wound, opens the tunica vaginalis and looks at the testicle. These precautions are necessary to prevent seeding in the event of a malignant tumor.
 
If the lesion appears malignant on clinical inspection, a radical orchiectomy is completed (54530). No biopsy is done. If uncertainty exists, the urologist may perform a biopsy.
 
For example, a patient visits the urologist because he feels something on his testicle. "The urologist feels it too," says Ira G. Keselman, MD, of Shore Urology in Long Branch, N.Y. "The patient has normal blood markers, but an area of calcification." The urologist performs a biopsy after clamping the cord and walling off the surgical field, Keselman says.
 
The urologist sends the specimen to the lab for a stat analysis. If the biopsy is positive, the urologist proceeds to a radical orchiectomy, billing 54530. The urologist should also bill for the biopsy. The needle biopsy (54500, Biopsy of testis, needle [separate procedure]) is not bundled into 54530; the incisional biopsy (54505, Biopsy of testis, incisional [separate procedure]) is. Bill 54505 with modifier -59 (Distinct procedural service) appended, in addition to 54530. The physician should be paid for the biopsy because it was necessary to determine treatment.
 
The reimbursement for needle biopsy (54500) is higher than that for incisional biopsy when performed in the office, yet an incisional biopsy (54505) requires more work, Keselman says. However, needle biopsies are rarely performed, and incisional biopsies are rarely performed in the office. "If you cut the scrotum and its case, you alter [...]