How to code for a perineal prostate biopsy

Jonathan Rubenstein, MD

Perineal biopsy has been performed since the early 1980s and has recently seen a resurgence. How should one code for performing a perineal biopsy?

Mark Painter

The typical code to use will be CPT 55700, which describes prostate biopsy by any approach. Imaging can be added if appropriately performed and documented.

There are 3 CPT codes that describe the sampling of prostate tissue by biopsy: CPT codes 55700, 55705, and 55706. Each is described below.

55700: Biopsy, prostate; needle or punch, single or multiple, any approach. CPT code 55700 is used for prostate biopsy by any technique, whether transrectal, perineal, or endoscopic. CPT code 55700 can be billed with or without imaging guidance, such as ultrasound, so imaging guidance can be billed separately if performed. This code should be reported once per session no matter how many cores are obtained, and there is no upper limit to the number of cores taken to bill 55700 once. The procedure may be performed in the nonfacility (office) or facility (ambulatory surgery center, hospital) setting. This procedure is a 0-global day procedure.

Note: Imaging for this procedure is often provided with transrectal ultrasound. We remind you that although in the past, Medicare allowed for reporting of both the diagnostic ultrasound (76872 ultrasound, transrectal) and ultrasound guidance (76942 ultrasonic guidance for needle placement [eg, biopsy, aspiration, injection, localization device], imaging supervision and interpretation), this is no longer appropriate, as they are now bundled. Many private payers are following Medicare’s lead and are also bundling the 2 codes. Therefore, when using ultrasound in conjunction with the biopsy code 55700, you will need to select the appropriate imaging code supported by the documentation and medical necessity.

55705: Biopsy, prostate; incisional, any approach. CPT code 55705 is the code to use for an “open” prostate biopsy, by surgical exposure of the prostate, with cores taken by direct visualization of the prostate. The work of this code includes obtaining tissue from the prostate by direct incisional sampling and specifically describes the need to make a surgical incision and tissue dissection to expose the prostate. The procedure may be performed in the facility (ambulatory surgery center, outpatient, or inpatient hospital) setting and is a 10-day global procedure.

55706: Biopsies, prostate, needle, transperineal, stereotactic template-guided saturation sampling, including imaging guidance. CPT code 55706 is used for the performance of a “saturation” biopsy. A true saturation biopsy is a unique procedure that is performed in specific indications and following the steps as defined by the American Medical Association (the owner of the CPT copyright):

• The patient has a prior suspicious biopsy, or a prior negative biopsy [result] with rising PSA [prostate-specific antigen].

• The procedure is performed in an operating room under general or spinal anesthesia.

• A template grid to map the (entire) prostate gland is used. This grid enables the physician to remove cores at 5-mm intervals using a stereotactic approach.

• Cores are taken at 5-mm intervals, and each specimen is labeled to correspond with the location of each core chosen. In deeper planes, both a proximal and distal biopsy may be obtained.

• Each biopsy sample is marked for its coordinates, and all are mapped in 3D to determine the extent and exact position of malignant cells.

• Typically, 35 to 60 biopsies are taken, based on the size of the gland.

CPT code 55706 should not be performed in the office setting, as there are no practice expense inputs to reimburse for supplies, clinical staff, or equipment. This is a 10-day global procedure, and imaging guidance is included so imaging cannot be billed separately.

Why is CPT code 55700 typically the correct code for performing a perineal biopsy?

Perineal biopsy is correctly reported using CPT code 55700 prostate biopsy, any technique. As stated in the descriptor, CPT code 55700 should be used for any technique of prostate biopsy, including perineal biopsy, no matter how many cores are taken and even if using a stepper or grid. This code was valued with consideration of the typical time, skill, and resource use for the performance of the procedure by any route, including both capital and disposable costs. As perineal biopsy was being performed when this code was valued, the time skill and resources needed for the performance of biopsy by any technique were included in the value.

It would not be proper to bill CPT code 55706 for a typical perineal biopsy. CPT code 55706 is to be used only for a saturation biopsy and only if the indications and steps outlined by CPT are followed. Although saturation biopsy is performed by the perineal approach, one should not confuse the definitions and choose CPT 55706 unless a true saturation biopsy is being performed, even if the perineal biopsy is extensive and performed in an operating room.

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at urology_times@mmhgroup.com.

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.