Urology Coding Alert

Hint: Needle size can help you distinguish.

The world of medicine includes numerous pinpoint-specific terms, but also has its fair share of terms that are used interchangeably – even though some shouldn’t be. That can especially be the case with common terms such as “biopsy,” but you can teach your providers to be accurate in their descriptions.

Your urologists may use “biopsy” as a universal term to state that they took a specimen sample. But does the specimen really qualify as a biopsy? Your job as a coder is to help ensure you understand what your provider means.

Here’s why: Vague documentation habits can contribute to coding errors involving these procedures, says Kelly Loya, CPC-I, CHC, CPhT, CRMA, associate partner at Pinnacle Enterprise Risk Consulting Services LLC located in Charlotte, NC.

Watch for Tissue Sample for Biopsy

Encourage your urologist to reserve “biopsy” for procedures to remove a small tissue specimen for diagnosis, whether open, laparoscopic, or percutaneous. A prostate biopsy is a procedure in which small samples are removed from the prostate gland with a special biopsy needle or during surgery, to be tested for the presence of cancer or other abnormal cell growth. If the urologist gets into the habit of classifying biopsies in this manner, you’ll know to look for the appropriate percutaneous needle biopsy (PNB) code if the op note shows a needle was involved.

If, however, the documentation shows that your physician removed cellular material (“aspirate”) instead of tissue in a biopsy, you’ll turn to the fine needle aspiration (FNA) codes.

Example: An example of a biopsy performed by a urologist would be the frequently performed needle biopsy of the prostate gland used to obtain a core of benign or malignant tissue from the prostate gland, says Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York Stony Brook.

“A fine needle aspiration (FNA) would be the removal of cellular material from a testicle with a fine needle to determine the presence or absence of sperm cells within the testicle during a fertility evaluation,” Ferragamo says. “A biopsy of the prostate provides a core of tissue for examination while aspiration of a testicle provides only cellular material for investigation.”

 Helpful hint: Code for FNA when your urologist does an aspiration of the testis or epididymis. Your physician may also use PNB for these organs. For the prostate, your urologist may almost always do a transrectal or perineal PNB to obtain prostatic material for analysis.

Example: When your surgeon performs a percutaneous needle biopsy (PNB) of the prostate, report code 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach).

Speed tip:  To quickly locate an exact PNB code, look up “needle biopsy” in the CPT^® index. Find the anatomical location your physician biopsied, such as the “epididymis,” and, presto, you can look up the specific CPT^® code to ensure it matches the procedure performed and documented. For biopsy of the epididymis, you would use 54800 (Biopsy of epididymis, needle).

Note: Your physician does not have to indicate the word “percutaneous.” Stating a “needle biopsy” in the procedure description is sufficient.

Also Think ‘Bigger’ for Biopsy

Other hints in the operative note to help you distinguish an FNA from a PNB are needle size and the specimen type.

“A percutaneous needle is much larger than a fine needle,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J.

Specimen: “A fine needle takes out an ‘aspirate,’ which is a sort of fluid sent to the pathologist for analysis,” Cobuzzi says. “A percutaneous needle is larger and takes out tissue in the mass’s core.”

Key terms: You should associate the terms “fluid” or “cell sampling” with FNA and “core” or “tissue sampling” with PNB. Remember that the urologist can perform prostate biopsy by several different methods: transrectal, perineal, transurethral, or open.

Mistakes could cost you: If you miscode a PNB as an FNA, you stand to lose significant reimbursement. For instance, if you had reported the earlier prostate example, the national average physician fee schedule (facility) reimbursement for 10021 is $58.02 compared to 55700 allowing $135.87, resulting in a difference of $77.85 when performing these procedures in hospital. When performed in the office, 10021 = $100.19 and 55700 = 256.60, resulting in a difference of $156.41 for a physician office error in coding.

Note: All payment values above are based on the unadjusted 2019 Medicare Physician Fee Schedule conversion factor of 36.0391.

Limit 55700: Your physician may obtain multiple tissue samples during a prostate biopsy, but that doesn’t mean you report the code multiple times. Remember, code 55700 includes single or multiple needle biopsies of the prostate gland. Do not bill 55700 multiple times or with multiple units. You should report only a single unit of code 55700 for each encounter for biopsy.

In addition to 55700, CPT^® includes two other codes for prostate biopsy:

• 55705 – Biopsy, prostate; incisional, any approach
• 55706 – Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance.

Take note: Code 55706 is payable only when the procedure is performed in a hospital facility, Ferragamo says.