Author: Kimberly Mansingh

Article

Prostate Saturation Biopsy (CPT 55706)

Kimberly Mansingh

A procedure I have received a couple of questions about recently is a prostate saturation biopsy. Coders have questioned how this procedure is different from a standard core biopsy of the prostate. They have also asked if you could support using CPT code 55700 which is used for a standard core biopsy, or if you have to report a distinct code for the saturation biopsy technique. Today’s article is dedicated to answering these questions and helping you code a prostate saturation biopsy with confidence.

Let’s start by comparing codes for a standard core biopsy of the prostate and then a unique code for the saturation biopsy technique:

CPT 55700: Biopsy, prostate; needle or punch, single or multiple; any approach

CPT 55706: Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance

The first thing to notice from the code descriptions is the difference in approach in these two codes. CPT 55700 for a standard core biopsy of the prostate can be performed by “any approach.” CPT 55706 for a saturation biopsy is performed strictly through a transperineal approach. A transperineal approach alone is not enough to confirm the saturation biopsy technique because again a standard core biopsy can be performed by “any approach” (which could include transperineal), but a transperineal approach should be taken as a clue that should make you ask more questions about the biopsy technique.

From there, we can see that the saturation biopsy is performed through a “stereotactic template guided” technique. The AMA published a great CPT Assistant article in November 2010 explaining this technique. If you have access to that resource, I would encourage you to check out this article for a full understanding. To summarize, though, the physician will use a template (grid) and stereotactic guidance to identify exact coordinates to obtain precise biopsies every 5 mm. Depending on the size of the prostate, physicians will take 35 to 60 cores on average (compared to 6 to 15 cores in a standard core biopsy). So the use of a template/grid plus a higher number of cores is an additional clue to look for in the operative report to distinguish a saturation biopsy from a standard core biopsy.  

The remaining details to identify a prostate saturation biopsy are more clinical and not necessarily written in the CPT code description. The first clue is the type of anesthesia used for the procedure. The standard core biopsy can be performed under local anesthesia in the office or with some sedation, but saturation biopsies require general anesthesia or spinal/epidural anesthesia in a facility setting. Finally, standard core biopsies are usually the first choice for an initial diagnostic biopsy (e.g., in a patient with an elevated PSA). Saturation biopsies, though, are typically performed in patients who had a prior abnormal core biopsy with need for more precise understanding of the cells in the prostate that may be impacted by cancer or suspicious lesions or patients with a normal standard core biopsy whose PSA is still on the rise. Use these clues to further distinguish a saturation biopsy technique from a standard core biopsy.

As to the code selected, while it may be tempting to just use code 55700 for all prostate biopsies since you are familiar with that code and it includes a biopsy “by any approach,” it is important to accurately report CPT 55706 for the saturation technique. The CPT guidelines tell us to select a code that is an accurate reflection of the procedure performed and not a mere approximation of that procedure. So it is important to take your time, carefully review the procedure details and indication, and ensure you select the best CPT code to represent the procedure documented.

References:

CPT Assistant, copyright American Medical Association, November 2010

Moffitt Cancer Center (clinical explanation of a prostate saturation technique): https://moffitt.org/cancers/prostate-cancer/saturation-biopsy/

Uncategorized

Coding Replacement of Subcutaneous Rhythm Monitors

Kimberly Mansingh

A subcutaneous rhythm monitor (sometimes referred to as an implantable cardiac monitor or an implantable loop recorder) is a device inserted into a pocket underneath the skin that provides long-term monitoring of the patient’s heart rate. Unlike a holter monitor which involves placement of electrodes and the use of an external recording device worn by the patient over a period of 2-15 days, these devices are useful for monitoring heart rhythm over a longer period of time when there is a need to better understand the trends and determine if a pacemaker is needed.

While most patients have the subcutaneous rhythm monitor inserted, are monitored, and then have the device removed (with or without placement of a pacemaker), some patients may require monitoring over a period of several years which could require replacement of the device. You will notice that we have clear codes for insertion of a subcutaneous rhythm monitor (33285) and removal of one (33286). But how is a replacement of this device coded?

It depends. There is no dedicated code for replacement of a subcutaneous rhythm monitor. There is also an NCCI edit between codes 33285 (insertion of the new device) and 33286 (removal of the old). The rationale for the edit is that the two codes represent “mutually exclusive procedures.” This means that the two codes cannot reasonably be reported together at the same anatomic site or at the same encounter.

So the final coding comes down to the timing of the two procedures and whether the new device is placed in the same location as the original device:

  • If the original subcutaneous rhythm monitor is removed and a new device placed through the same incision, code for the insertion of the new device only (33285). I would apply this same guideline even if there is some “tunneling” under the surface of the skin to create a new pocket for the replacement device– one incision equals code 33285 only.
  • If, however, the old subcutaneous rhythm monitor is removed and a new device is placed through a separate incision you can report 33285 and 33286 with modifier 59 (or modifier XS) to show that the new device is inserted through one incision and the old device removed through a separate incision at a separate anatomic site. As an example, you may see this in patients who have an infection in the location where the original monitor was inserted with a need to move the new device to a completely different location away from the infection.
  • You could also report 33285 and 33286 with modifier 59 (or modifier XE) if for some reason the old monitor was removed during one encounter and the new monitor was inserted at a separate encounter later on the same day. This would be very rare, but I did want to cover the coding of this scenario in case you see it in your coding.

References: