Prostate needle biopsies

Patient has undergone aTransrectal ultrasound-guided prostate needle biopsies.

I have coded it as:
55700 and 76872.
Do I need to add any modifiers to the radiology code?
Procedure:
Patient taken to cystoscopy room. IV sedation was administered by anesthesia staff. He was put in lithotomy postion. A transrectal ultrasound probe was passed through the anus and into the rectum. Biopsies were taken from12areas within the prostate. We sampled the base, mid gland and apex medially and laterally on each side. The sides were sent separately for analysis.

re: Prostate needle biopsies

If in a hospital setting, modifier -26 to radiology code(s).
76872, 76942
76872



Ultrasound, transrectal

It is the standard of care to perform a sonographic evaluation of the prostate for any abnormality prior to a prostate biopsy. These abnormalities will be shown as hypoechoic areas or lesions that need further diagnostic investigation. This sonographic evaluation determines whether the physician should continue with prostate biopsy. A separate report for this diagnostic evaluation is required. This formal report should be signed by the physician and included in the patient's chart.

76942

Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation

As described above, if there are questionable areas the physician will normally continue with the sonographically guided biopsy of the prostate. To obtain specimens of the questionable areas, it is important that the physician direct the biopsy needle accurately and this type of sonogram is an essential part of the procedure to assure the proper placement of the needle.

In addition to the ultrasound codes, it is appropriate to bill the biopsy code:

55700

Biopsy, prostate; needle or punch, single or multiple, any approach

In a hospital setting, when a urologist and a radiologist perform the prostate biopsy procedure together, the urologist reports CPT® code 55700 and the radiologist reports CPT® code 76942. If the urologist performs the CPT® code 76872, Ultrasound, transrectal, then he should append modifier -26, Professional Component. If the radiologist performs the transrectal ultrasound prior to the ultrasonically guided prostate biopsy, then the radiologist would bill using CPT® code 76872.

It is also important to include a written report on the ultrasonic guidance procedure. This report may be either separately documented or included within the report of thttp://www.auanet.org/content/health-policy/practice-management/coding-tips/ultrasound.cfm#prohe procedure.

re: Prostate needle biopsies

Thank you for the information. Have a great day!