Case
-T10-2C TRANSRECTAL ULTRASOUND
LOCATION: Outpatient, Hospital
PATIENT: John Ibarra
SURGEON: Ira Avila, MD
PREOPERATIVE DIAGNOSIS: Possible recurrent prostate cancer
POSTOPERATIVE DIAGNOSIS: Possible recurrent prostate cancer
PROCEDURE: Transrectal ultrasound and biopsy of
prostatic nodule
CLINICAL NOTE: This gentleman had a radical prostatectomy by me 6 months ago. His prostate-specific antigen is now 0.1 ng/ml (nanograms per milliliter). He had a repeat prostate-specific antigen a few weeks after this at the VA. This showed an undetectable prostate-specific antigen level. On rectal examination, though, there is a little nodule in the prostatic fossa.
PROCEDURE: Patient was placed in the left lateral position. Ultrasound probe was introduced. The nodule could not be identified by ultrasound. There is no palpable mass. Bladder neck was open. Images were not obtained.
Probe was removed with digital guidance, and nodes were biopsied twice. Patient tolerated the procedure well. I will contact him when results are available.
If the biopsy is benign, I think we will try and write the abnormal prostate-specific antigen off to laboratory error given the fact that he has had a normal one since then. We will schedule him for prostatic-specific antigen and follow-up in 3 months.
PATHOLOGY REPORT LATER INDICATED: Benign prostatic tissue specimen
T10-2C:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question

Quizplus · Accepted Answer

The Answer is Professional Services: 55700 (Prostate, Needle Biopsy), 76872-26 (Ultrasound, Rectal) ICD-10-CM DX: N40.0 (Enlargement/enlarged, prostate), Z85.46 (History, personal [of], malignant neoplasm [of], prostate)
Explanation: The prostate was transrectally biopsied and reported with 55700. The ultrasound of the prostate was a diagnostic exam and performed independent of the biopsy and is reported separately with 76872. Note that the ultrasound probe was removed and then the physician used his finger to identify the site and guide the biopsy. This means that the biopsy was performed without ultrasound guidance; therefore, 76942 is not appropriate. The -26 modifier is added when reporting the professional service.
The pathology report indicates benign prostatic tissue specimen. Therefore, the indication for biopsy would be coded, which is a little nodule in the prostatic fossa (N40.0). When referencing "Nodule, prostate" in the Index of the ICD-10-CM the coder referred to "Enlargement, prostate," N40.0. When referencing this code in the Tabular, the code accurately reports the condition stated in this report. This patient also has a history of prostate cancer (Z85.46).

Case -T10-2C TRANSRECTAL ULTRASOUND