tci Outpatient Facility Coding Alert - 2017 Issue 3

You Be the Coder: Ultrasound with Prostate Biopsy

Question: Please share if you think that the following note substantiates a diagnostic ultrasound: “Transrectal US/guidance for a needle biopsy/needle biopsy. Technique: ‘Transrectal US was subsequently performed. A lidocaine periprostatic block was performed under US guidance. 12 biopsies of the prostate were subsequently performed in sextant fashion with ultrasound guidance. The patient tolerated this well.’” Florida Subscriber Answer: No, this documentation does not support a diagnostic ultrasound. Here’s why: In order to bill for a diagnostic ultrasound with 76872 (Ultrasound, transrectal) or TRUS, the physician must document the diagnostic results of the ultrasound. These...

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