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Aetna Ins is telling us we cant bill 52000 with 55700 (even though 2 separate area and 2 separate dx and edits do not bundle the codes) they say CMS guidelines state they are inclusive when performed in conjunction with each other does anyone know where there guidelines are--I cant find them does anyone else have this problem with Aetna? thanks

SuperCoder Answered Mon 20th of November, 2017 07:54:57 AM

Hi Sue,

The code 52000 is designated as a separate procedure which are routinely viewed as an integral part of another more extensive procedure and need to be separate sessions, separate incisions, separate lesions, etc. If the provider performs 52000 to verify the appropriateness of the biopsy 55700, then there would be no medical necessity to support billing it with a modifier. If the needle biopsy of the prostate and seminal vesicles is performed via a noncystoscopic approach, report 55700 (biopsy, prostate; needle or punch, single or multiple, any approach). If a cystoscopy is performed as a separate procedure in addition to the needle or punch biopsy, then 52000 (cystourethroscopy [separate procedure]) can be reported with modifier -59 (distinct procedural service). According to the CPT, a biopsy via endoscopy is always coded with a single code, therefore a cystoscopy code would not be reported additionally in this case.

You may check with your medical records for biopsy, if it is with endoscopy then only one code will be billed. Please feel free to ask for any further query.

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