Pathology/Lab Coding Alert

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 providers’ 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 the patient did, in fact, undergo 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 for the pathologist to analyze,” 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:

• 76942 (Ultrasonic guidance for needle placement …)
• 77002 (Fluoroscopic guidance for needle placement …)
• 77012 (Computed tomography guidance for needle placement …)
• 77021 (Magnetic resonance imaging guidance for needle placement …)

Use 57005 for Incisional Biopsies

Should your pathologist obtain a prostate tissue sample for biopsy that was obtained 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:

• 55700 is performed under local anesthesia; 55706 under general anesthesia.
• 55700 can be performed using any approach, though it is often performed using a transrectal (passing through the rectum) approach; 55706 represents a transperineal (passing through the perineum, the area between the scrotum and the anus) approach.
• 55700 samples 6-12 tissue cores; 55706 samples 35-60.
• 55700 does not include imaging guidance; 55706 does (Source: CPT^® Assistant, Vol. 20: Issue 11, Nov. 2010).

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:

• 55812 (Prostatectomy, perineal radical; with lymph node biopsy(s) (limited pelvic lymphadenectomy))
• 55842 (Prostatectomy, retropubic radical, with or without nerve sparing; with lymph node biopsy(s) (limited pelvic lymphadenectomy))
• 55862 (Exposure of prostate, any approach, for insertion of radioactive substance; with lymph node biopsy(s) (limited pelvic lymphadenectomy))

You would not use these codes as they are for prostate biopsies a surgeon performs on their own in conjunction with a surgical procedure on the prostate.