Urology Coding Alert

Question: The physician inserted a transrectal ultrasound (US), and the prostate was measured and found to be approximately 42.3 g in size. The area near the bladder neck, which was a possible median lobe, was confirmed to be a prostate cyst. There was also a smaller cystic structure on the posterior aspect, as well as some moderate calcifications. At this point, the perineum was anesthetized, along with the apex of the prostate with 10 mL of lidocaine. My physician then used a spinal access needle and traversed the middle portion of the prostate until he cannulated the anterior cyst and aspirated out the contents, which were a bloody content with no purulence or other concerning findings. The patient also had a cystoscopy and a transperineal PrecisionPoint biopsy done. Which codes should I report for this scenario?

AAPC Forum Member

Answer: You should report the following coding for your clinical scenario:

• 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach), if your physician biopsied the prostate gland
• 10005 (Fine needle aspiration biopsy, including ultrasound guidance; first lesion)- XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service) for the aspiration of the prostatic cyst
• 52000 (Cystourethroscopy (separate procedure)) for the cystoscopy