Prostate cancer is the most common cancer in men and the second leading cause of cancer-related deaths in men in the U.S. If prostate cancer is detected early, it may be possible to treat it successfully. This cancer is diagnosed through biopsy of the prostate gland. A prostate biopsy can be performed using different techniques such as transrectal, perineal, transurethral, and open. A urology medical billing service provider can help physicians report prostate biopsies using the correct CPT codes.
Urologists usually order a biopsy of the prostate is if an abnormality is found on the digital rectal exam (DRE) or the prostate-specific antigen (PSA) test. The prostate biopsy involves using a needle to remove a small amount of tissue from the prostate gland for laboratory analysis. Performed under anesthesia, a fine needle aspiration biopsy typically uses ultrasonic guidance. Sound waves guide the needle into a mass or region to obtain a specimen. A prostate biopsy can detect prostate cancer.
Different methods are used to collect biopsy samples. The two common approaches to prostate biopsy are:
- Transrectal biopsy: The biopsy needle is passed through the wall of the rectum
- Transperineal biopsy: The needle is inserted through the area of skin between the anus and scrotum.
A saturation biopsy retrieves more tissue samples from a tumor site than a standard biopsy. While a standard biopsy typically removes just 12 to 14 tissue samples, a saturation biopsy systematically retrieves 20 or more samples at one time. So a saturation biopsy provides a wider selection of cells to test for cancer. This approach is generally used for high-risk individuals with previous negative biopsies when a clinical suspicion of cancer exists.Saturation biopsy may be performed transrectally or using the transperineal approach, which is usually a stereotactic template-guided procedure with general anesthesia.
According to the American Urological Association (AUA), typically, 35-60 biopsies are taken, based upon the size of the gland. The AUA states that a true saturation biopsy is a very involved procedure with specific indications and defined steps:
- Patient has a prior suspicious biopsy, or a prior negative biopsy with rising PSA
- The procedure is performed an operating room under general or spinal anesthesia
- A template grid is used to map the (entire) prostate gland, which allows the physician to remove cores at 5-mm intervals using a stereotactic approach.
- Cores are taken at 5mm intervals, and each specimens is labelled to correspond to location of each core chosen. Both a proximal and distal biopsy may be obtained in deeper planes.
- Each biopsy sample is marked for its coordinates, and all are mapped in 3D to determine the extent and exact position of malignant cells.
Coding Biopsy for Diagnosis of Prostate Cancer
The CPT code selected should be an accurate reflection of the procedure performed and not a mere approximation of that procedure. There are three CPT codes to report biopsy for diagnosing prostate cancer: CPT 55700, CPT 55700, and CPT 55706.
- Standard core biopsy: The code for a standard core biopsy of the prostate is:CPT 55700: Biopsy, prostate; needle or punch, single or multiple; any approachCPT code 55700:
- Is used to bill a standard core biopsy of the prostate performed using any approach, unless the specific work described in CPT code 55705 or CPT code 55706 is performed.
- Can be reported without or with imaging guidance (ultrasound or MRI) and if performed, imaging guidance can be billed separately.
- Should be reported once per session regardless of how many cores are obtained
- Procedure may be performed in the non-facility (office) or facility (ASC, hospital) setting. (Medicare National Correct Coding Edits and other edits by commercial insurers may impact reporting of imaging.
- Is a 0-day global procedure
- Open prostate biopsy: The CPT code to report an open prostate biopsy is:CPT 55705 Biopsy, prostate; incisional, any approachCPT code 55705:
- Is used for an “open” prostate biopsy, by surgical exposure of the prostate, with cores taken by direct visualization of the prostate
- Involves obtaining tissue from the prostate through direct incisional sampling, and also describes the need for a surgical incision and tissue dissection to expose the prostate
- may be performed in the facility (ASC, Outpatient or Inpatient Hospital) setting
- Is a 10-day global procedure
- Saturation biopsy: The CPT code to report a saturation biopsy is:CPT 55706 Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidanceCPT code 55706:
- Is used to report biopsy, prostate; needle or punch, single or multiple, any approach when performed without stereotactic template guidance
- May involve ultrasound guidance reported with code 76942 (ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, and localization device], imaging supervision, and interpretation)
- Meant to allow for the systematic collection of samples from the entire prostate gland and not for sampling
- Should not be used for an initial biopsy
- Cannot be performed in the office so there are no practice expense inputs except for supplies, clinical staff and equipment used in the follow-up office visits included in the global period.
- Is a 10-day global procedure with 3 hours and 15 minutes of total time included
The BlueCross BlueShield of Tennessee Medical Policy Manual states that a saturation biopsy (more than 20 cores) is considered medically appropriate if ALL the following are met:
- At least one prior negative biopsy
- Clinical suspicion of cancer (e.g., persistently elevated, or rising PSA)
Medicare’s HCPCS G code G0416 (surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method) can also be reported for the surgical pathology associated with this procedure as well as other prostate needle biopsies.
Urology medical billing is complex. Providers of urology medical billing and coding services are knowledgeable about the specific codes and rules involved as well as payer guidelines. Partnering with an expert can ensure medical coding compliance, avoid denials, and ensure optimal reimbursement.