Know when to go beyond 55700. Confused as to which code to use when your provider performs a prostate biopsy on a patient? If you are, it’s not surprising. Altogether, the CPT® index lists six codes under biopsy, prostate: three are specific to prostate biopsies, and three more reference biopsies as part of different surgical procedures that a provider might perform on a patient’s prostate. So, to help you eliminate the guesswork involved in picking the right code, we’ve broken down the codes for you, helping you match them to your provider’s notes with ease and precision. Avoid the 55700 Temptation The first prostate biopsy code that might leap out at you will probably be 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach). But reaching for this procedure code automatically could create several problems.
First, you’ll need to verify your provider did, in fact, perform a percutaneous needle biopsy (PNB). If the procedure was a fine needle aspiration (FNA) biopsy, refer to the note accompanying 55700, which tells you to apply an FNA biopsy code from 10021-10012 (Fine needle aspiration biopsy …), depending on whether the provider used image guidance for the procedure or not. Hint: “A fine needle takes out an ‘aspirate,’ which is a sort of fluid sent to the pathologist for analysis,” while “a percutaneous needle is larger and takes out tissue in the mass’s core,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPCO, CPC-P, CPC-I, CENTC, CMCS, of CRN Healthcare Solutions in Tinton Falls, New Jersey. FNA biopsy codes are always found in the general surgery section of CPT®, while PNB codes are found in the relevant anatomic sections. Remember: The descriptor for 55700 does not include mention of imaging guidance, which means you should follow the note accompanying the code and code separately for any ultrasonic, fluoroscopic, computed tomography (CT), or magnetic resonance imaging (MRI) the provider uses to aid in the PNB using one of the following: Use 57005 for Incisional Biopsies Should your provider obtain a prostate tissue sample for biopsy by making an incision, you’ll use 55705 (Biopsy, prostate; incisional, any approach). This open prostate biopsy procedure surgically exposes the prostate, allowing the provider to visually examine it to obtain core samples. Decide Between 57000 and 55706 On the surface, 55706 (Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance) is a needle biopsy that looks very similar to 55700. However, this biopsy, often referred to as a saturation biopsy, differs from 55700, often called a standard sextant biopsy, in several ways: Remember: 55706 is payable only when the procedure is performed in a hospital facility. But if you do use the code, you should follow the note accompanying it, which tells you not to use the code in conjunction with 57000.
Medicare alert: When billing Medicare for a saturation biopsy, be sure to use HCPCS Level II code G0416 (Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method). This code is reported by the pathologist for a Medicare needle biopsy specimen. For non-Medicare patients, you’ll use 88305 (Level IV - Surgical pathology, gross and microscopic examination … Prostate, needle biopsy …) if the specimen is from a needle biopsy. Avoid Prostatectomy Codes for Prostate Biopsy Last, the CPT® index lists three other codes for biopsies performed in conjunction with a surgical procedure on the prostate: You would not use these codes for prostate biopsies your surgeon performs on their own.