55700

Biopsy, Prostate; Needle or Punch, Single or Multiple, any Approach

CPT code 55700 represents the surgical procedure of obtaining tissue samples from the prostate gland using a needle or punch device. This procedure is the gold standard for diagnosing prostate cancer and is typically initiated after clinical findings such as an elevated Prostate-Specific Antigen (PSA) level or an abnormal Digital Rectal Examination (DRE). The procedure can be performed via several anatomical approaches, including transrectal, transperineal, or transurethral, though the transrectal ultrasound (TRUS)-guided approach is most common in an office setting. During the procedure, the patient is usually placed in the lateral decubitus or lithotomy position. Local anesthesia is often administered as a periprostatic nerve block to minimize discomfort. Using a biopsy 'gun' or a spring-loaded needle device, the physician extracts thin cores of tissue from various zones of the prostate. While a standard biopsy typically involves a 12-core sampling template—covering the base, mid-zone, and apex of both the left and right lobes—CPT 55700 accounts for any number of samples taken during the session. The physician may also perform targeted biopsies of suspicious lesions identified on pre-procedure Multiparametric MRI (mpMRI), often utilizing MRI-ultrasound fusion technology. After the tissue is retrieved, the specimens are placed in fixative and sent to pathology for histological examination to determine the presence of malignancy, Gleason score, and the extent of involvement. Post-procedural care includes monitoring for signs of infection, hematuria, or urinary retention.

Clinical Indications

  • Elevated Prostate-Specific Antigen (PSA) levels
  • Abnormal Digital Rectal Examination (DRE) finding such as a nodule or asymmetry
  • Suspicious findings on Multiparametric MRI (mpMRI) documented by a PI-RADS score of 3 or higher
  • Active surveillance monitoring for patients previously diagnosed with low-risk prostate cancer
  • Rising PSA velocity or PSA density in patients with previously negative biopsies
  • Evaluation of a prostatic mass identified during other diagnostic imaging
  • Suspicion of prostate cancer recurrence following radiation or other primary therapies

Procedure Steps

  1. Patient is positioned, typically in the left lateral decubitus position with knees and hips flexed.
  2. A digital rectal examination is performed to assess the prostate and identify any palpable abnormalities.
  3. A transrectal ultrasound probe is inserted to visualize the prostate gland and measure its volume.
  4. Local anesthesia is administered, often as a periprostatic nerve block under ultrasound guidance.
  5. The biopsy needle is introduced via the ultrasound probe's biopsy channel (transrectal) or through the perineum.
  6. The physician fires the biopsy needle into specific segments of the prostate gland to obtain core samples.
  7. A standard template (usually 12 cores) is followed, sampling the peripheral zone where most cancers occur.
  8. Targeted cores are taken if specific lesions were identified on prior imaging (e.g., MRI-fusion).
  9. Each tissue core is carefully removed from the needle and placed in labeled specimen containers.
  10. Pressure is applied or a rectal pack is briefly used if significant bleeding occurs.
  11. The ultrasound probe is removed, and the patient is monitored for immediate complications before discharge.

Coding Guidelines

  • CPT 55700 includes single or multiple biopsies performed during the same operative session.
  • Ultrasonic guidance for the needle biopsy should be reported separately using CPT 76942.
  • If a diagnostic transrectal ultrasound is performed prior to the biopsy, report 76872.
  • Do not report 55700 in conjunction with 55706, which refers to a transperineal stereotactic saturation biopsy (typically 20+ cores).
  • For a fine needle aspiration (FNA) of the prostate, use 10021 or 10004-10012 instead of 55700.
  • The biopsy may be performed in an office, ambulatory surgery center (ASC), or hospital outpatient department (HOPD).
  • Pathology services (e.g., 88305) are billed separately by the pathologist.

Associated ICD-10 Codes