Urology Coding Alert

There is no defined set of codes that you should report every time your urologist performs prostate biopsies you have to take into account who was present and where the service was rendered. Prostate biopsies can be performed with or without the presence of a radiologist and in both facility and nonfacility settings. According to C.J. Wolf, MD, CPC, a senior consultant for an integrated healthcare system in Utah, prostate biopsies are almost always done under ultrasonic guidance, and the large majority of the time they are also performed in addition to transrectal echography. And it is up to you to sort through the documentation before determining which of the following codes you should report for the urologist's services: CPT 55700 Biopsy, prostate; needle or punch, single or multiple, any approach
CPT 76942 Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation
CPT 76872 Echography, transrectal.

"The bottom line is if your documentation supports all three services, then all three codes should be reported," Wolf says.

"A lot of payers may recommend distinct dictations for the ultrasound guidance and the transrectal echography," Wolf says, but that doesn't mean they have to be separate dictations. Just be sure the dictation indicates that the urologist performed two separate services, the prostate biopsy under ultrasonic guidance and the transrectal echography. Report Code 55700 Every Time Regardless of where the prostate biopsies are performed and whether a radiologist is present, you will always need to report code 55700 for your urologist's service. Code 55700 represents the biopsy procedure itself, in which the radiologist usually takes no part. But three different scenarios will affect how and when you should report codes 76942 and 76872. 1. Facility setting with the radiologist present. If a urologist performs a prostate biopsy with ultrasonic guidance and a transrectal echography in the hospital or other facility setting, we can assume the hospital owns the radiology equipment. Let's also assume that there is a radiologist in the room supervising the radiology procedures during the prostate biopsy and documenting an interpretation and report of the findings. Because the urologist is only performing the biopsy and is not supervising and interpreting the ultrasonic guidance and transrectal echography, 76942 and 76872, the urologist can only report 55700. The hospital will report both the technical and professional components of the radiology services for the radiologist who was present. 2. Facility setting without a radiologist present. Now let's assume the urologist performs a prostate biopsy with ultrasonic guidance and a transrectal echography in the hospital setting (he doesn't own the equipment) and there is no radiologist present during the surgical session. The urologist not only documents taking the biopsy but documents [...]