Urology Coding Alert

Question: Our transrectal ultrasound (TRUS) claims are hit and miss - sometimes the carrier pays them when performed for prostate nodules, and other times it denies  them as not medically necessary. How do carriers decide whether they are going to reimburse this service?

Louisiana Subscriber
 
Answer: In the past, most Medicare carriers as well as many private carriers would not reimburse for a TRUS with a diagnosis of benign prostatic hypertrophy (600.0) or a nodular prostate (600.1). They viewed this as a screening (or a non-payable) service.
 
Many offices used ICD-9 codes 222.2 (Benign neoplasm of male genital organs; prostate) or 239.5 (Neoplasm of unspecified nature; other genitourinary organs) to ensure payments.
 
Recently, several carriers, including some Medicare carriers, have realized the necessity to ultrasonically measure prostate size and prostatic urethral length before performing minimally invasive procedures such as transurethral microwave therapy (TUMT, 53850) and transurethral needle ablation (TUNA, 53852), and have added prostatic ICD-9 codes 600.0-600.9 to the list of acceptable diagnoses for TRUS (76872, Echography, transrectal).
 
If your physician only performs a TRUS-guided needle biopsy, you should report 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) for the ultrasonic guidance and 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach) for the biopsy. If the urologist is working with a radiologist in a hospital or office setting, only report 55700 for the urologist's services, and the radiologist should report 76942.
 
In a third scenario, your urologist may perform a transrectal ultrasound followed by a needle biopsy with ultrasonic guidance. If this is the case, report 76872, 76942 and 55700. Many carriers will reimburse all three services provided that the patient's diagnosis supports medical necessity. Empire Medicare Services (a New York and New Jersey carrier), for example, will reimburse all three services when linked to 185 (Malignant neoplasm of prostate), 236.5 (Neoplasm of uncertain behavior of genitourinary organs; prostate) or 790.93 (Elevated prostate specific antigen [PSA]). Most important, check with your local carrier before deciding how you should report your TRUS services.