Wiki Case #14 Winner, Answer Key, & Rationale

[alex.mckinley@aapc.com]

Amanda G. won case #14. See below for the answer key and rationale.

ANSWER KEY
CPT: 52235, 55700, 76942-26 or 52235, 55700-51, 76942-26
CPT Modifiers: 26 or 51, 26
ICD-9: 239.4, 790.93

RATIONALE
During the procedure the provider performs an ultrasound guided prostate biopsy and transurethral resection of bladder tumors. Multiple bladder tumors are resected. When selecting a code, choose based on the largest tumor resected, do not report a code for each tumor. The code for the prostate biopsy is only reported once because the code description states ?single or multiple.? A code for the ultrasound guidance is reported with 76942. You do not report 76872 because it is reported for a diagnostic ultrasound and in this case the ultrasound is used only for the guidance.


CPT: 52235, 55700, 76942-26 or 52235, 55700-51, 76942-26

Steps for look up: Resection/Tumor/Bladder; Biopsy/Prostate. There is a parenthetical statement instructing to report 76942 for imaging guidance.

Modifier 26 is appended for the professional component. Depending on the payer, modifier 51 can be appended to 55700. You would not report modifier 59 or X{E,P,S,U} because there is not an NCCI for the codes reported for this case. We also accepted answers that did not include modifier 26 or 51.

The postoperative diagnosis is a bladder tumor. Because we do not know the behavior of the tumor, it is reported as unspecified. You also code for the elevated PSA to support the prostate biopsy.

ICD-9-CM 239.4, 790.93

Steps to look up: Tumor- see also Neoplasm, by site, unspecified; Neoplasm/bladder (urinary)/wall/posterior/unspecified; Neoplasm/bladder/trigone/unspecified; Elevation/prostate specific antigen (PSA)

 

[tmorgan808]

I thought you had to have measurements even though it says medium?

 

[cmontyrn]

Case # 14 clinical added for Answer key & Rationale

Case # 14 clinical added for Answer key & Rationale
Since the clinical info wasn't included in posting of answer & rationale; and the link to case clinical info given now is not accessible (error page shows up) .... I thought it wise to include the missing original clinical info.

Hint: The operative report for Case 14 include anesthesia and a biopsy in an outpatient setting. CCI Edits and lay terms as well as ICD-10-CM coding knowledge will really help with this case.


Case #14

https://www.aapc.com/code/aapc-coding-challenge/cases.aspx


OPERATIVE REPORT

PREOPERATIVE DIAGNOSES:

1. Elevated prostate specific antigen of 3.8.

2. Bladder tumor, medium posterior wall of bladder and trigone, multifocal.

POSTOPERATIVE DIAGNOSES:

1. Elevated prostate specific antigen of 3.8.

2. Bladder tumor, medium posterior wall of bladder and trigone, multifocal.

OPERATION:

Transrectal ultrasound of the prostate with ultrasound-guided prostate biopsies and transurethral resection of bladder tumor in the median posterior wall and trigone.

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: 75cc

INSTRUMENT COUNTS: Correct times two.

DESCRIPTION OF THE PROCEDURE IN DETAIL:

The patient was brought to the operating room in the outpatient surgical center and, following the induction of general anesthesia, he was placed in the left decubitus position. A transrectal ultrasound probe was introduced into the rectal vault, and the prostate was scanned in the transverse and longitudinal planes. There were no hyper- or hypoechoic areas noted, and the prostate volume was approximately 38 cc. Sextant biopsies of the right and left lobe of the prostate were performed including left and right base and lateral base, left and right mid gland and lateral mid gland, and left and right apex and lateral apex. Each biopsy core was performed under transrectal ultrasound guidance and sent for pathologic review.

The patient was subsequently placed in the dorsal lithotomy position, and the penis and scrotum were prepped with Betadine, and a drape was placed. The urethra was calibrated to 30 French with a van Buren sound, and the resectoscope sheath was advanced into the bladder. The Iglesias resectoscope was placed through the sheath and connected to continuous flow irrigation with sterile water.

The tumor was noted behind the right trigone, was of medium size, and there were multifocal areas of smaller bladder minors on the right trigone well lateral to the right ureteral orifice, whose position was marked using the cutting mode of the Bovie through the loop. Resection was performed of the bladder tumor including body and base of bladder tumor of the larger one and subsequently the smaller ones, including muscle, in the specimen. Any bleeding was controlled with point coagulation of bleeding points with Bovie electrocautery through the loop. All visible tumor was removed, and hemostasis was achieved. The tumor chips were irrigated out of the bladder, and second-look cystoscopy revealed no residual tumor, normal-appearing ureteral orifices intact and no significant bleeding.

The resectoscope was removed, and a 20-French Foley catheter was advanced through the bladder, placed to bag drainage. The patient?s anesthesia was reversed, and he was transported to the recovery room in satisfactory condition.