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Welcome to episode 306 of the Eurogy Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. And on today's podcast, we want to talk about prostate biopsy coding and reimbursement. And you can find this information on the PRS Coding and Reimbursement Hub. So if you go to PRSnetwork.com forward slash urology hub, under the categories, you'll see a prostate biopsy page. And you can go and check out the information that we're going to be discussing on the podcast today. So you'll have this information going forward. And there's also a lot of other information on the PRS coding and reimbursement hub. You'll see that we have added some new pharma information as well as some other categories. So we're adding to it, adding new categories and new products as we move forward. So we're hoping to add that at a much quicker pace. So you'll have this as your resource to go to check out all those products that the sales reps may be talking to you about. We've gone through and vetted it to make sure that the coding and reimbursement is correct. So you don't have to. You can rely on us. We've we'll give you the sources and we'll let you know what we think. And a lot of times we do work with these companies and make sure that their information is right as well. So all right, with that, Mark, you want to talk about prostate biopsies?

All right. So a couple of different things that we've got to consider with prostate biopsies. So number one, we've talked a lot about the new codes that came out for 2026. And we've briefly discussed in our proposed rule discussion the code changes that are coming up for 2027. The changes are relatively minor, judging from what we've seen as a peak into what's going to happen in 2027. So let's just go ahead and start that essentially we now have multiple prostate codes. They're really broken up by a couple of different parameters, let's say. So the first part is approach. We have our standard transrectal approach. Those have specific codes: the 55707, the 55708, and the 5571 as our base codes for transrectal. Then we have transparineal codes that really mirror the guidance portion of it, but are focused on the transparineal approach, which are the 55709, the 55710, and the 55712. The second, and then we have a third grouping, which are the inbore or CT or MRI guided biopsies. So those are kind of our major categories. Then we have some subdivisions, subsidiaries, subsets of those particular codes that are really focused on how much or what your targeting is for the biopsies, and then again a subset driven by the imaging that's there. And actually, I'm gonna flip that around and say we have a subset of codes that are driven by the imaging equipment that's used, and then within that, we have a breakdown a little bit within the actual targeting within the prostate that is there. So we'll start first with imaging. If you're using straight ultrasound, essentially the transrectal approach is 55707 and the transparineal is 55709. These replace that old 55700 code and the 76872 with the guidance. And I want to stop a little bit here because we've gotten a couple of different questions on guidance. It's been interesting to watch the lack of activity in the NCCI or the bundling edit rules. And I've gotten several questions from coders and billers and from ambulatory surgical centers that have noted that currently in the NCCI, codes 76942 and 76872 are not actually listed as bundled into either of these codes. When you look at the CPT manual, it's very clear that guidance and any type of imaging is bundled into the current prostate biopsy codes. What I'm going to tell you is I believe it's just a matter of time before the NCCI catches up. So if you're putting those codes in, the 76872 or the 76942, in addition to the 55707 or 55709, you may get paid for those based on the current adjudication engine that Medicare has. The problem is Medicare can and often institutes retroactive bundling edits. And because the CPT description and the pricing that was set up for in-office and for the facility, it's clear that those services were bundled into the codes. So it's only a matter of time before Medicare fixes that adjudication engine and will very likely come back and take back that revenue stream. And I will have to tell you that based on what we know about this, I think that this could be considered fraudulent billing because you are knowingly billing for a service that is by definition and by the reimbursement bundle put into those particular codes. So I would highly discourage you from taking advantage of the lack of CMS or NCCI's efforts to build out the full NCCI at this point in time. So again, my recommendation, do not do it. It is one of those things and it follows the rules. Just because you can get paid for a thing doesn't mean you should. So I want to put that caution in early in. So let's go back now to the overall focus on ultrasounds. So ultrasound biopsy coding and the way it's set up is not based on the number of cores that you take, nor is ultrasound coding based on the number of targets that you are using for that particular patient's biopsies. It is a one-size-fits-all code, kind of like the old 55700. It doesn't matter how many cores you take, it doesn't matter your targeting. If you're using the ultrasound as the guidance for your codes, you either choose based on the transrectal or the transparineal. Now the 55708 and 55711 in the transrectal approach add in MRI fusion guidance. Now we've and so do the transparineal approach of 55710 and 55712. There are slight differences in these codes based on your targeting. And this is where that differentiation is part of it. We need to make sure that you understand that fusion is defined in CPT as the MRI is fused on a workstation with an appropriate appropriate equipment. It's not something that should be used for those cases in which you are cognitively fusing the ultrasound and the MRI. It needs to be done on a separate workstation. The 55708 and the 55710, again, dependent on approach, are for those cases in which you are performing a systematic or a s or a uh a targeted uh biopsy or a excuse me, a biopsy of the entire prostate, a random sampling of areas within the prostate plus a targeted lesion. If it's transparineal, it's a 55710, again, transrectal 55708. So you need both the full biopsy of the prostate, the systematic biopsy, and a targeted lesion. The 55711 and the 55712 are for those cases where you don't need the systematic biopsies or the regional biopsies of the prostate, but are focused on a targeted lesion. That's when you, again, depending on approach, the 55711 transrectal or the 55712 for transparineal. So that's kind of that differentiation. It's focused on the first targeted lesion. The AUA has come out with a position, and it looks like, again, from our preview of the 2027 code set, that if you do not have a targeted lesion, then it is considered not medically necessary for you to use fusion. And the ultrasound codes would be appropriate, the 55707 for the transrectal and the 55709 for the transparineal. So if you don't have a targeted lesion, use the ultrasound codes, and that's going to change next year in the verbiage from again from what we believe is going to happen as we look at next year. So it's important to understand what your targeting is, what equipment you're using, but also make sure that you are really taking a look at the approach. That all needs to be well documented, not just in the order, but in your operative note. And we've got some examples of documentation specifically listing which equipment you're using. So if you are doing a targeted lesion, for example, and you're using a Coelis machine for that, or the Trinity machine from Coelis, you want to put that in the note as well as that the MRI was fused on a separate workstation. Make sure that you note that you're you have a target and where that target is located or a region of interest. And then if you perform a systematic biopsy as well, note the areas that you tip biopsies from and use the 55708. If you are just going after a targeted lesion, note where the lesion is and use the 55712. If you have more than one lesion on a particular patient, we have an add-on code, the 55715, which is from CPT's perspective, for each additional targeted lesion, and it doesn't matter approach, whether it is transrectal or transparineal, each additional lesion would be billed with the 55715. Unfortunately, Medicare put an MUE on that particular code, so you may have to appeal if you're doing more than two lesions. So if you're doing a third lesion, which you would bill using two units of 557115, and then one unit of the base prostate biopsy code, you may have to appeal that with medical records and documentation to demonstrate that you had more than one lesion or region of interest for that particular code. And again, that documentation is going to be key, making sure that you are clear as to where you took biopsies from, where were your regions of interest. You of course want to document the number of cores, even though that doesn't affect how you code. You want to make sure you're using the appropriate ICD 10 codes, and that needs to be part of that order. And then again, as a circle back and a reminder, what equipment did you use? And was, if it's fusion, did I have a lesion? And did I have the separate fusion on the machine?

Ready? Comments, questions?

No, that's uh a very detailed discussion of what you have to do. And Scott, I was just reviewing your information on the hub. So anybody that needs a refresher on what Mark said, why they can go to the hub and read your published information on the prostate biopsy and get a nice refresher on the same information.

Yeah, I I agree. Uh, Mark, you did a great job of explaining it. And yes, there is a refresher on the hub, goes through the same information and hopefully explains it just as well. I do have a couple questions for you. One is the Z code. Can you build the Z85.46 personal history of malignant neoplasm of a prostate and have that as the primary reason for you doing the targeted lesion?

So it is one of those diagnosis codes that should probably not be on its own when it's when you're looking at the diagnosis of this. So that would be, in this case, most likely a follow-up biopsy. So you do want to have in the first position the actual reason why you're re-biopsing this patient. Either you felt another nodule or the PSA's rising, something of that type, maybe an abnormal finding on an image, any of those symptom or diagnosis codes should be listed first, and the Z code should be listed second. All right.

And then just curio I was curious, are there any, are you seeing any specific denials going on or audits specifically targeting these codes in 2026?

So we haven't yet seen a lot of activity auditing these codes at this point in time. But we have seen a few medical record requests, and we have seen a few come back because the documentation of the lesion was not clear. So that's that that's one of the fails that we saw in in the overall approach. And but we haven't seen a lot of activity focused yet on the specifics of fusion versus ultrasound. I think those are a little bit more sophisticated. We still have seen some problems here and there on prior authorizations, although those are decreasing at this point in time as payers are finally catching up with the 2026 code changes.

All right. And uh the other thing I will mention, and Mark had mentioned the Coelis Trinity, and do appreciate Coelis working with us on this. And there is a prostate biopsy code matrix as well that has these codes listed in a PDF that you can download on the hub if you go to prsnetwork.com forward slash urology hub. So that's you'll be able to see under the code matrix guides on one of the drop-down menus, and you can look for the prostate biopsy tools that we have there.

All right. Scott, I did want to mention one more thing. And okay, I talked a little bit about the the ultrasound codes, the 76872 and the 76942. That we have a facility coding tab on the hub page. And some of the questions that I received for billing the ultrasound guidance or the diagnostic ultrasound were from ambulatory surgical centers because the status that is assigned to the 76872 does state that Medicare would allow for payment of the 76872 in addition to a surgical procedure that it was inherent to. And again, I go back to the same issue that I brought up with the physician in stating that, yeah, it might actually pay because of the status and the and we don't know and have the same visibility into the OCE, which is the counterpart for the billing bundling matrix in the NCCI for the ambulatory surgical center hospital side. But I do I would also put that same caution out to the ASC. One, you might not get a match if the physician is billing appropriately and not including the 76872. So you might get a denial. But if there was billed out of both and it got paid, I do again think that's subject to recoup and further activity with Medicare. So I want to put that caution in there as well. All right.

Okay. Well, the one final thing I'll ask you and before we move on to to wrap this episode up is transparental biopsies in the office. There's been a lot of questions about that.

What do you how do you answer that when you get those questions? So the bottom line it's about clinical appropriateness and whether or not the physician feels that they can provide that service for the patient with enough comfort to the patient and ultimately your numbing of the perineal area with a local. An aesthetic is not something you can bill for, in addition. Certainly the reimbursement is a little bit more attractive for transparineal, and there are a number of folks out there that feel, based on medical literature, that the transpareneal biopsy is the better approach. And for some patients, it is the better approach. It is something that is not restricted to being in an ambulatory surgical center. The patient is not required to be under MAC or anesthesia from a CPT coding perspective. So basically, I would tell individuals that are considering this is what is your clinical skill? What do you think you can do for your patients? And do you feel it's medically appropriate to do this in your office? And that's a clinical call that I'm not willing to make. It's certainly available from a reimbursement side, but it is something that ultimately a clinician could decide to do. And we do have some physicians that feel comfortable with their ability to inject the appropriate anesthetic for the patient and conduct those transparineal biopsies in the office. So it can be done from a coding perspective. I've heard it done from a clinical perspective, but it is something something of a balance from a patient and clinical efficacy perspective. All right.

Okay. Well, let's wrap this episode up here. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com forward slash PRS network for specials for our listening audience. Also, I want to remind you that the Urology Advanced Coding and Reimbursement Seminar is coming up very soon in December in Las Vegas and another one in New Orleans in January. So if you want to have these discussions and learn about everything that's going on, that we can let you know that we know of. There's a lot happening in urology, and we'd love to share that and have those discussions, as well as tap into the collective genius in the urology community for all the attendees. So really encourage it. It's nice to get away with like-minded folks that are dealing with some of the same problems you are. So you can go to PRSnetwork.com, and right there on the homepage is a seminar registration button where you can get some more information on that and the pricing. All right. Let's get some final thoughts. Mark, what are your final thoughts today?

Well, one is ultimately the same thought we have just about every time. Documentation is key. Making sure that you're following these guidelines. I mean, certainly there are a lot of things you can do to shortcut the amount of work it takes with the tools we have with electronic medical records. But you do want to make them truly patient specific, making sure that you have any documentation clinically relevant to that patient, especially the targets and the number of cores. Definitely include the equipment to support the fusion on a separate machine. And then the other part of this is again going back to that overall caution. Make sure you're billing based on the rules that we know are going to be applied, even if some of the administrative work that Medicare should have done hasn't been done yet. So do do the right thing and you will be compliant with all of this. I was gonna say you're gonna be rewarded, but in the end it's just part of the game.

You'll be in a better position. You'll be in the right position, how about that? All right, Ray, final thoughts.

Well, I'm usually the broken record on this team always talking about documentation, but Mark stole my thunder. So I'll just say ditto, and remember, the devil is in the detail.

All right. Okay, and uh final thing that I'll add is we do want to recognize and thank all of our industry partners that do support the hub. Those are the companies that are really committed to making sure we get these things right that are working with us and working with us on the hub. So we really appreciate those industry partners. And again, you can go to PRSnetwork.com forward slash urology hub to check that out. All right, that's all we have for today. Thank you all for listening. Take us out, right?

Happy coding. Thank you for listening to the Uralogy Coding Remembers the podcast, where we help urologists and their staff maximize income and efficiency, so there's time and energy for taking care and a happy life. So thank you for interesting today. You can find 50 different on Spotify under it, but a total of T2.