Wiki Prostate BX

Bokeelia, FL
Best answers
My doctor is using codes 76872, 76942,55700 and code 64430. I am questioning the use of the 64430 because of the LCD on this code, he is trying to use DX code of high PSA and that is not on the LCD list. I am just questioning where or not the injection is part of the BX itself or if we really should be using the 64430 and just need to find a different DX.

Thank you
not my area of expertise - but, I'd say "no" to the 64430 code.
Actually, according to the CDR - the 64430 is typically used for perineal pain control for example during vaginal delivery :eek: (though it is used for anesthesia of the perineum, rectum and parts of the bladder and genitals. and code 64435 is a female only code.

I think his "injection" code IS included in the 76872, 76942,55700 codes.

BUT, I just checked the CCI edits - and, it says we CAN use 64430 w/ 55700 but of course you'd need a .59 modifier on the 64430. hmmmm

hopefully someone with some expertise in this area can help you, afraid my answer(s) only made more confusion! sorry
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Jennifer, do you mean to use CPT 64450 instead? Is this in an office setting? If so, yes, you can use the following code order: 55700, 76872, 76942, and 64450-59 (injection, anesthetic agent; other peripheral nerve or branch.) If it gets denied, I appeal it stating that the services were performed in an office settting. Procedure 55700 is a painful one; therefore, a nerve block is necessary to prevent pain (CPT 64450). Modifier-59 has to be used and of course, documentation must support all the charges. I hope this helps.

Zaida, CPC
Urology office
If you look at the LCD list high PSA is not a covered DX for 64430 or 64450. We can try and appeal it, have you billed Prostate BX this way and has it been paid.
The order of codes I indicated in my last post is the way we submit our claims. The few times we have to appeal this (with most private payers), we do get paid. To be safe, you should check with your payer(s) and their policies.

Medicare will not pay for the prostate block in this situation, as they consider itincluded in the procedure (I am in WI). Our urologist insisted that we bill it to commercial, even though we argued that most insurance companies follow Medicare guidelines on this. Anyway, at the end of the year we got a letter from BlueCross asking that we reimburse them for all the prostate blocks we billed them as it is included in the procedure. So we are not billing any prostate blocks anymore.

My feeling on this is that in the CCI edits it states that 64430 is a component of 55700, so unless the prostate block is given for a different reason (such as relieving the pain the patient is having on an ongoing basis for example or another procedure being done where it is not included) you should not use 64430 even with a modifier. You would have to have documented in the doctor's note that this is a separately indentifiable procedure from the prostate Bx.
One more thing, just in case you are wondering, 64450 is also included with 55700 in the CCI edits. So I should have included both codes in my previous post. Thanks
I just got word from my A/R urology counselor as well to stop billing for this code...some were paying for a while, but not anymore.