Code This!

Assign the appropriate ICD-9-CM diagnosis code(s), CPT procedure code(s), and HCPCS Level II code(s) for the following scenario:

Preoperative diagnosis: Prostate cancer, clinical stage T2a

Postoperative diagnosis: Prostate cancer, clinical stage T2a

Procedure performed: Cystoscopy with cryosurgical ablation of the prostate

Procedure: The risks and benefits of the procedure were again explained to the patient and his family, and informed consent was obtained. He was taken to the operating room. After adequate induction of general endotracheal anesthesia, he was placed in a dorsal lithotomy position. After performing flexible cystoscopy, a Foley catheter was inserted into the bladder. A transrectal ultrasonography (TRUS) probe was inserted into the rectum. The entire prostate was visualized by ultrasound and re-measured. The probe template was then positioned over the perineum and the template guide brought up on the ultrasound screen for needle placement guidance. Then 17-gauge needles were placed into the prostate, from an anterior to posterior direction. Five rows of needles were placed as follows: row #1: 3 needles; row #2 at the level of the mid-prostate: 4 needles; row #3 in the right lateral peripheral zone: 2 needles; row #4 urethra: 1 needle; and row #5 left lateral peripheral zone: 2 needles.

Ultrasound guidance demonstrated the needles were well placed and spaced throughout the prostate to obtain excellent freezing of the entire gland while sparing the urethra. The urethral warmer was passed into the bladder and flow initiated. The prostate was frozen down to minus 150 degrees for 10 minutes in sequential fashion from anterior to posterior. The ice ball was monitored and was seen to extend through the capsule of the prostate toward the rectum but not through the rectal wall itself. Active warming was performed before refreezing the prostate again and then passively warming it back to room temperature. The urethral warmer was left on after removal of the needles. The patient tolerated the procedure well and was sent to the post anesthesia care unit in satisfactory condition.

Code this scenario with ICD-9-CM, CPT and HCPCS Level II codes.

ANSWERS

ICD-9-CM Code
185 Malignant neoplasm of prostate

CPT Code
55873 Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring)

HCPCS Code
C2618 Probe/needle, cryoablation

The prostate is a walnut-sized gland in the male. It surrounds the neck of the bladder and its ducts empty into the prostatic portion of the urethra. The prostate contributes fluid that helps to liquefy semen. Adenocarcinoma of the prostate is the most common form of cancer in males older than 50 in the United States. Symptoms are uncommon until late in the disease course, when ureteral obstruction and hematuria may occur.

Locate the appropriate diagnostic code for this condition in the ICD-9-CM alphabetical index using the neoplasm table. Under the main terms “Neoplasm, neoplastic,” locate the subterm “prostate.” Under the columns indicating “malignant” and “primary,” code 185 is found. Verify the code in the tabular section.

Find the correct procedure code for the cryoablation in the CPT index under main term “Prostate” and the subterms “Ablation” and “Cryosurgery” which reference code 55873. Verify the code in the tabular section.

Find the correct HCPCS Level II code for the cryoablation probes in the HCPCS index under the main term “Probe” and subterm “cryoablation” which references code C2618.

Cryoablation probes are hollow needles (cryoprobes) through which coolant is circulated.

Cryoprobes are inserted into or placed adjacent to diseased tissue. Ablation occurs in tissue that has been frozen by at least three mechanisms: 1) blood flow disruption by coagulation; 2) membrane disruption by the creation of ice crystals within the cells; and 3) initiation of apoptosis.

According to HCPCS Coding Clinic, Third Quarter 2006, HCPCS codes are used to report drugs, biologicals, magnetic resonance angiography (MRA), certain implantable medical devices, and new technology services that must be used by OPPS hospitals. HCPCS codes are reported for these procedures that do not have other HCPCS code assignments. Non-OPPS hospitals, Critical Access Hospitals (CAHs), Indian Health Service Hospitals (HIS), hospitals located in American Samoa, Guam, Saipan, or the Virgin Islands, and Maryland waiver hospitals may report these codes at their discretion. Individual payers may be contacted regarding their policy for accepting HCPCS codes under their systems.