What is CPT Code 55700?
CPT code 55700 describes a prostate needle biopsy performed to detect prostate cancer or other abnormalities. Providers such as urologists typically use this code when performing biopsies via various approaches—transrectal, transperineal, or transurethral—to obtain tissue samples from the prostate gland. This biopsy procedure is primarily indicated for patients with elevated prostate-specific antigen (PSA) levels, abnormal digital rectal exams (DRE), or suspected prostate cancer identified through imaging.
Accurate reporting using the 55700 CPT code helps healthcare professionals standardize documentation, ensure proper reimbursement, and improve the prostate cancer detection rate, particularly when monitoring patients following prior negative biopsy results.
What is a needle biopsy of the prostate?
A needle biopsy of the prostate, often called a prostate needle or punch biopsy, is a diagnostic procedure in which small tissue samples are extracted from various regions of the entire prostate gland. The biopsy needle, specifically designed as a biopsy prostate needle, ensures minimal tissue disruption and maximal precision during sampling.
Ultrasound guidance is frequently utilized to enhance the accuracy and effectiveness of biopsy procedures, such as transrectal ultrasound-guided biopsy. An initial negative prostate biopsy doesn't always eliminate the possibility of a subsequent prostate cancer diagnosis, highlighting the importance of careful follow-up and potential repeat biopsies. This biopsy helps diagnose prostate cancer, determine its aggressiveness, or confirm the absence of disease after an initial biopsy was inconclusive.
CPT Code 55700 documentation requirements
Complete and detailed documentation is vital to support billing and clinical decision-making associated with CPT code 55700.
Indication for biopsy
Clearly document the clinical indication prompting the biopsy procedure, such as elevated prostate-specific antigen (PSA), abnormal digital rectal exam (DRE), or suspected prostate cancer on imaging. If a repeat prostate biopsy is performed, document prior negative biopsy results.
Biopsy technique
Indicate the specific approach used—transrectal, transperineal, or transurethral—for the prostate needle biopsy. Also, document whether imaging guidance (such as transrectal ultrasound-guided biopsy) was utilized to improve prostate cancer detection.
Number of cores sampled and anatomical zones
Precisely document the number of tissue cores obtained, including the specific anatomical zones of the prostate sampled. Accurate details help pathologists better identify clinically significant cancer versus clinically insignificant prostate cancer.
Imaging guidance
If imaging guidance was employed during the biopsy procedure, clearly note the modality (ultrasound, MRI fusion, etc.) used for biopsy targeting. Proper documentation supports separate billing for imaging guidance services.
Anesthesia type
Specify the type of anesthesia administered during the biopsy (local, moderate sedation, general, or spinal anesthesia). Clearly stating anesthesia type supports appropriate billing when anesthesia is provided separately.
Complications and patient instructions
Document any procedural complications and provide clear post-biopsy instructions given to the patient. Accurate documentation of post-procedure care enhances patient safety and supports clinical accountability.
Pathology submission details
Include details about pathology submission, specifying how samples were labeled, handled, and sent to pathology for prostate imaging reporting and diagnosis.
CPT Code 55700 billing guidelines
Proper billing ensures compliance with payer guidelines and accurate reimbursement.
Report once per session
Bill CPT 55700 only once per biopsy session, regardless of how many cores or samples are taken from the prostate gland during the procedure.
Imaging guidance billed separately
Imaging guidance, such as transrectal ultrasound (CPT 76942), can be billed separately if documented clearly and utilized during the procedure. Verify payer coverage for imaging guidance.
Anesthesia billed separately if applicable
Moderate sedation or general anesthesia administered by another provider may be billed separately. Clearly document the anesthesia services provided, distinct from the biopsy itself.
Post-procedure care included
Post-procedure follow-up care and instructions are considered bundled into CPT 55700. Separate billing for routine aftercare services is generally not permitted.
Verify payer guidelines for repeat biopsies
Payers may have specific guidelines regarding the frequency of repeat prostate biopsies and limits on pathology reimbursement. Always verify payer-specific rules to ensure compliance.
Other Relevant CPT Codes
- 76942 – Ultrasound imaging guidance for needle placement
- 88305 x n – Pathology interpretation (billed per prostate core)
- 55706 – Saturation biopsy, template-guided, prostate gland
- 55899 – Unlisted procedure, male genital system
- 76872 – Ultrasound, transrectal prostate
Frequently asked questions
Yes. If ultrasound or other imaging guidance is medically necessary and clearly documented, you may bill it separately using CPT code 76942. Check specific payer guidelines to confirm coverage.
Local anesthesia administered by the performing provider is included. Moderate sedation, general or spinal anesthesia performed by another qualified provider can be billed separately if properly documented.
Yes. Pathology interpretation can be billed separately per core using CPT code 88305 for each prostate core sample submitted. Verify payer-specific limits or restrictions on the number of cores billed per session.
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