Transrectal ultrasound for prostatic evaluation has two codes depending on whether the ultrasound is diagnostic or for guidance during a procedure. If the urologist performs a diagnostic ultrasound, use 76872 (echography, transrectal). If ultrasound guidance is used for a prostate biopsy, use 76942 (ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) for the guidance and 55700 (biopsy, prostate; needle or punch, single or multiple, any approach) for the biopsy.
However, payers have different limitations on ultrasound codes being used together. Most have incorporated a catch-22: They will pay for an ultrasound with a diagnosis of prostate cancer, but if you already have the diagnosis, you don't need to perform the biopsy.
Some carriers will cover both ultrasounds on the same day if the first (76872) is clearly diagnostic; others will only cover the needle guidance (76942).
The Evaluation and Biopsy
Typically, a patient is referred to the urologist by a primary care physician for an elevated prostate specific antigen (PSA), says Jan Brunetti, CPC, billing coordinator for Urology Associates in Newport, R.I. For this initial consultation, the urologist codes a consultation (99241-99245) with a diagnosis of elevated PSA (790.93). The patient determines if a biopsy is performed, Brunetti says. "They have a choice between 'watchful waiting' and a biopsy," she says.
If the patient elects to have a biopsy, the next visit is coded 76942 for the ultrasound and 55700 for the biopsy with 236.6 (neoplasm of uncertain behavior of genitourinary organs; other and unspecified male genital organs) linked to both codes, Brunetti says. If you do not own the sonographic equipment, append modifier -26 (professional component) to the guidance code. "We append modifier -26 to the 76942 because another company owns the ultrasound machine," she explains.
Because Brunetti's group does not perform the initial ultrasound, it does not need to bill 76872.
Carrier 'Bundling' CCI
doesn't bundle 76872 and 76942, but Medicare carriers and private payers may still refuse to pay for both, says Morgan Hause, CCS, CCS-P, coding specialist with Urology of Indiana. "No matter what the diagnosis, we can't get paid for both," he says. In fact, urologists in Indiana can only get paid for 76872 with an elevated PSA or prostate cancer. "We can't ever bill 76872 for a nodule," Hause says.
Although a diagnostic ultrasound before a biopsy is usually unpayable, after the biopsy (55700) you can get paid 76872 if the biopsy shows cancer. Urologists use a diagnostic ultrasound of the prostate (76872) in a patient with prostate cancer to see how large the prostate is, Hause says. "If it's too big, they will put the patient on Zoladex or Lupron before proceeding with other treatments." [...]