Wiki TRUS Prostate Injection

[Sunshine Rose]

We are new to urology coding. Not sure if we are lacking the right documentation, or if the code for this is just unclear to us.

Does anyone know what CPT codes we would report for this procedure?

Pre Op Dx: Recurrent, refractory chronic prostatitis
Post operative: Same
Procedure: TRUS prostate injection.

Risks and benefits including bleeding, infection, pain/discomfort, need for further procedures, urosepsis, failure to diagnose a clinically significant prostate cancer were discussed. Peri-operative antibiotics were given.
Anesthesia: Local

Pt was brought back to the procedure suite and placed in the right lateral position. A stop and pause identifying the patient, the operative site and surgeon was undertaken. Ultrasound probe was advanced into his rectum. Volumetric survey was undertaken. Volume calculated at 26.41 cc. Lesions: None. Other findings: None
Injection: After local anesthesia was provided 1 g of Rocephin was injected into either lobe of the prostate in 2 needle passes per side. The patient tolerated the procedure well
The probe was withdrawn, procedure was terminated.

 

[liqgold2@aol.com]

I would suggest the followin coding for your clinical scenario:
96372 for the injection into the prostate, and
76872 for the trus of the prostate.

 

[renee868]

I know this is an older thread so I hope someone responds. I have a provider that performs TRUS prostate biopsies and administers Rocephin intramuscularly before the procedure, the admin code is bundled to CPT 55700 and he wants credit for this and wants it to be unbundled. Any thoughts on if this is acceptable to bill with modifier 59?

 

[svt96cobra]

I know this is an older thread so I hope someone responds. I have a provider that performs TRUS prostate biopsies and administers Rocephin intramuscularly before the procedure, the admin code is bundled to CPT 55700 and he wants credit for this and wants it to be unbundled. Any thoughts on if this is acceptable to bill with modifier 59?

If the IM Rocephin is meant for a prophylactic purpose, the inj fee is included in the proc. Depending on the place of service, you could bill for the drug itself but not the admin fee. The 59 modifier would be reserved if it were a condition that is not related to the biopsy or something that is not usually provided during a biopsy. (ABX prior to a TRUSBX are common)