Category: Article

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/

At the end of each year, there is always a rush to learn about the CPT updates that will go into effect on January 1^st. While it is important to get up to speed on what has changed (which is why we have created training modules to bring you that new information), the New Year also makes me step back and reflect on old concepts as well. It is a great time to ensure you have your latest coding resources downloaded and to renew your understanding of long-established codes as well.

With that in mind, today’s article will focus on three modifiers that are not new, but are critical for all surgery coders to understand: modifiers 58, 78, and 79. All three modifiers may be reported when a procedure is performed during the global period of a prior procedure. Let’s start with a look at how these modifiers are defined and some helpful tips that can ensure you use them appropriately.

• Modifier 58: Modifier 58 is often thought of as the “staged” modifier. While that is partially correct, modifier 58 has more to its definition:
  • Use modifier 58 when a procedure performed during the global period was planned at the time of the initial procedure (e.g. a colectomy is performed with the abdomen left open intentionally, and then the patient is brought back to the operating room for planned closure of the abdomen two days later) –or-
  • When the procedure performed in the global period is more extensive than the initial procedure (e.g., a breast mass is excised, but when the pathology comes back as cancer, a lumpectomy is performed in the global period) –or-
  • For therapy following a diagnostic surgical procedure (e.g., a patient undergoes open thrombectomy and then thrombolysis therapy is started a few days to resolve residual clots during the global period)

• Modifier 78: Modifier 78 is reported for an unplanned return to the operating room when the procedure performed during the global period is related to the original procedure:
  • Use modifier 78 when treatment of a complication of the initial surgery results in a return trip to the operating room (e.g., a surgeon performs an open aortic valve replacement and then has to take the patient back to the operating room 2 days later to control mediastinal bleeding) –or-
  • When the procedure performed in a global period is related to the original procedure and was not planned at the time of the initial surgery (many examples may apply but most often you will see treatment of complications) –or-
  • When the same CPT code is reported for treatment of complications in the global period of a prior procedure (e.g., the surgeon performs ORIF of the radius, but the patient suffers a re-fracture due to her osteoporosis and a fall at home so ORIF is repeated in the global period)

• Modifier 79: Modifier 79 is reported for an unrelated procedure performed in the global period of the original procedure:
  • Use modifier 79 when a completely unrelated procedure is performed in the global period of the original surgery (e.g., initial surgery is ORIF for hip fracture and second surgery is ORIF for a humerus fracture) – or-
  • When the same CPT code is reported for the surgery performed in the global period of the original procedure, but does not represent the same procedure performed at the same anatomic site (e.g., cataract surgery on the left followed by cataract surgery on the right in the global period)

Here are some additional tips for using global modifiers correctly:

• Global modifiers are used when the patient has a second surgery in the global period with the same surgeon or a surgeon in the same specialty/group practice:
  • Do not apply global modifiers if the patient is in a global with a surgeon outside your practice.
  • Do not apply global modifiers if the patient has a procedure with a surgeon in a different specialty in the same group practice (e.g., patient had surgery with orthopedics which put them in a global but then has a procedure with cardiology in the global period)
• Modifier 78 specifically requires a return to the operating room:
  • An operating room may be formally labeled an operating room or could be an equivalent space (e.g., procedure room, cath lab)
  • For Medicare and payers following Medicare’s guidelines, do not code the treatment of complications that do not require a return to the operating room separately (e.g., incision and drainage of a wound infection in the office). Check the policies for your private commercial carriers to see if they follow Medicare or have their own policy.
• Modifiers 79 and 58 may be reported for procedures that occur in the operating room during a global period, or they may be reported with unrelated or staged procedures/therapy that occur outside of the operating room, but still in the global period.
• Each CPT code is assigned a global indicator on the Medicare Physician Fee Schedule: 000, 010, 090, MMM,XXX, YYY, ZZZ:
  • The first three indicators refer to the number of global days for that procedure (i.e., 010 is assigned to a code with 10 global days)
  • MMM indicates a maternity code, and the usual global period does not apply
  • XXX indicates that the global concept does not apply
  • YYY indicates a code where the Medicare contractor determines how many global days apply
  • ZZZ indicates a code that is related to another service and always included in the global period (e.g., add on code)
  • Why does this matter? Many Medicare contractors state that you should not apply modifiers 58, 78, or 79 to a code with an XXX or ZZZ global indicator because these codes will be allowed without any global modifier. Some payers may just view the modifier as not required, but others may consider it an error and reject a claim if you apply the global modifier to a code with those indicators. So be aware of that guidance and check your global indicators when assigning these modifiers

Finally, a great place to get additional information about how to use global modifiers correctly is in fact sheets published by your local Medicare Administrative Contractor (MAC). To find these sheets, you can Google “modifier __ (e.g., 78) fact sheet,” and you should get search results right at the top for fact sheets from your MAC. Here are a couple of examples from Novitas and Noridian:

https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144546

https://med.noridianmedicare.com/web/jeb/topics/modifiers/78

I hope that is a helpful refresher for you on global surgery modifiers. One of the great things about coding is that no matter how long you have been in the field, there is always more to learn. Happy New Year, and thank you for letting me be part of your coding journey!