Urology Coding Alert

Many urologists are incompletely reimbursed for prostate biopsies due to payer bundling. Correctly dealing with this bundling is essential to keeping your overhead in check and avoiding fraud.

The code combination for a prostate biopsy is 55700 (biopsy, prostate; needle or punch, single or multiple, any approach), 76872 (echography, transrectal) and 76942 (ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation). Medicare and many private carriers will pay for all three, but many HMOs will not. The payers bundled the 78672 into 76942, refusing to acknowledge the value of the transrectal ultrasound (TRUS) prior to guidance biopsy. They dont understand that the ultrasonic guidance is not a full sonogram. Hypoechoic areas lesions that need biopsies can be missed unless a full TRUS is performed.

If you fail to receive payment for all three codes, especially for the TRUS, there are five ways to fight back:

1. Appeal (see Appeals Letter on next page).

2. Refer the patient out to the radiologist for the procedure.

3. Bill all three codes and write off what isnt paid (not the best option, but one you might end up doing anyway).

4. Do the initial sonogram several days before the biopsy itself. This isnt popular with patients, however.

5. Use a different diagnosis code for the biopsy than for the TRUS. For example, use 600.0 (hypertrophy [benign] of prostate) or 600.1 (nodular prostate) for the TRUS (76872), and 239.5 (neoplasms of unspecified nature; other genitourinary organs) or 236.5 (neoplasm of uncertain behavior of genitourinary organs; prostate) for the guidance (76942) and biopsy (55700). Add modifier -59 (distinct procedural service) to 76872 to indicate that the TRUS is being performed for a different reason.

On many occasions, nothing will work with an HMO, and the urologist must eventually write off the TRUS.