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Coding & Billing
Prostate Biopsy Technique in Search of a CPT Code
Lisa Weston
Publish Date: October 10, 2007   |  Tags:   Financial Management

If your surgeons are performing a new procedure to collect prostate biopsies, you'll likely have a hard time getting paid for it.

For one thing, there's no CPT code for stereotactic transperineal prostate biopsy, only alphanumeric code 0137T, a temporary code that carriers use for tracking and trending purposes. The only way that some surgical centers may be getting reimbursed for the procedure is by billing it as 55700 (biopsy of prostate), but this isn't sound strategy.

Additionally, most third-party payers consider transperineal biopsy using ultrasound guidance to be experimental or investigational and won't reimburse for it. However, literature suggests that transperineal biopsy using ultrasound guidance is not only superior to transrectal biopsy in terms of accuracy, but may be preferred for select patients.

Coding Catch-22
Stereotactic transperineal prostate biopsy, or STPB, was developed to establish the presence of occult carcinoma and define its localization within the prostate.1 In one week last month, the Chicago Prostate Cancer Center in Westmont, Ill., performed 14 STPBs, each taking about 45 minutes of OR time and done under general anesthesia. Saying the procedure isn't "medically necessary," Medicare denied reimbursement when the center filed them under 0137T. So the center now files them as 55700 - reimbursable in suburban Chicago at $130.99, up from $94.50 last year. Don't bill this way unless a carrier has requested in writing that it wants you to bill the procedure this way.

"We're waiting for someone to solve this problem," says Jennifer T. Cichon, the administrative director of the Chicago surgery center that's dedicated to the treatment of prostate cancer. "There needs to be a new code specific to this type of biopsy."

As you probably know, transrectal ultrasound guided sextant biopsy is normally reported with one of two codes:

  • 55700. Biopsy, prostate; needle or punch, single or multiple, any approach for the biopsies.
  • 76942. Ultrasonic guidance for needle placement (biopsy, aspiration, injection, localization device), imaging supervision and interpretation for the ultrasound guidance.

However, these codes are not appropriate for saturation biopsy for prostate mapping. The note that follows 55700 in CPT directs you to Category III code 0137T (biopsy, prostate, needle, saturation sampling for prostate mapping) for this procedure. A parenthetical note explains that 76942 is not to be coded in addition to 0137T. This is because ultrasound guidance is an integral part of the procedure and therefore included in the code, according to CPT Changes 2006: An Insider's View. Regardless of how many cores your surgeon takes, code 0137T once.

Transperineal vs. Transrectal Biopsy

In addition to increased comfort, there are several technical advantages to a transperineal approach of collecting prostate biopsies as compared to a transrectal approach, as outlined in a paper published in the October issue of Journal of Urology:

  • Rectal wall penetration by the biopsy needle is avoided and may translate into a lower risk of infection;
  • using sagittal imaging, the anterior apical biopsy specimen can be obtained with excellent visualization; and
  • the use of a perineal template is more objective as the localization and sampling is based on coordinates on a template.2

The transperineal patient is placed in the dorsolithotomy position. With the use of a stabilizer, the prostate is placed on a brachytherapy grid so that a transrectal ultrasound (TRUS) template can be obtained.2 The prostate template is divided into sections (normally eight sections or octants) and a number of biopsies are taken from each section. Depending on prostatic volume, anywhere from 20 to 80 TRUS-guided specimens are obtained. For mapping purposes, the cores are placed in specimen containers labeled with the section of the prostate and coordinates of the location from where they were taken, as seen in the photo below. This lets the physician correlate any lesion with a location in the prostate.

Not only is the transperineal procedure believed to be more comprehensive than systemic sextant biopsy, and therefore more likely to reveal malignancies, but the mapping lets the physician identify the location and the extent of the tumor. This mapping lets patients with localized prostate cancer forgo radical prostatectomy in favor of a recently developed focal tissue ablation procedure.

- Lisa Weston, CPC, CCS

For hospital outpatient departments paid under CMS' Outpatient Prospective Payment System, CPT code 0137T has been assigned to APC 00184 effective Jan. 1, 2006, with a status indicator of "T" denoting surgical services for which payment is allowed under the hospital OPPS. Services with this payment indicator are the only services to which the multiple procedure payment reduction applies.

For ASCs paid under Medicare Part B, the picture is less rosy. There has been no ASC group rate assigned to code 0137T, so there's no facility payment when this procedure is performed in an ASC. Contact your payer to verify coverage.

Exercise Caution When Going Out of Network

Operating out of network isn't as easy as it used to be, as insurers reject or try to recoup payments and negotiate tighter exclusive contracts. Here are thoughts on operating in part as an out-of-network facility.

  • Full waiver. Even with full disclosure to the payer, the riskiest strategy is to routinely waive co-payments, co-insurance or deductibles.
  • Partial waiver without disclosure. Another highly risky strategy is to match in-network benefits, but not to tell the payer.
  • Partial waiver with disclosure. A moderately risky strategy is to couple some discounts or in-network benefit matching with full disclosure to the payer. You might waive some co-payments, co-insurance or deductibles (preferably discounts rather than complete waivers), or you might not collect deductibles (but this practice should be limited to situations in which you have a reasonable and good faith belief that the patient's deductible obligation is being met through payments to other providers).
  • Partial waiver with disclosure and let payer reduce payment. A slightly less risky strategy is to match in-network payments but also let the payer pay a similarly discounted in-network charge. A state or payer could view this as a waiver or discount, particularly if you're not authorized by the payer or if the payer pays more than its share of the total amount paid. Here again, full disclosure is critical.
  • Charge out-of-network based on payer's payment. Here you charge the patient the out-of-network full payment amount based on what the payer pays rather than on the usual and customary charge. Full disclosure to the payer is important.
  • Case-by-case reduction of co-payments based on need; full disclosure to payers. A less risky strategy is to waive or reduce co-payments, co-insurance or deductibles on a case-by-case basis considering each patient's need and circumstances. With this approach, financial need may be based on the federal or poverty guidelines. Fully disclose to the payer that you're waiving or reducing co-payments, co-insurance or deductibles.
  • Charge full co-payments. The least risky of all strategies is to charge the patient the out-of-network full co-payment, co-insurance or deductible based on the your center's usual and customary charges. - Scott Becker, JD, CPA

Mr. Becker ("[email protected]")) is a co-chairman of the healthcare department at McGuire Woods in Chicago.

1. Moran BJ, Braccioforte MH, Conterato DJ: Re-biopsy of the prostate using a stereotactic transperineal technique. J Urol, 176: 1376, 2006
2. Moon K, Theodorescu D: Does saturation biopsy improve prostate cancer detection? Nat Clin Pract Urol, 3: 468, 2005