Prostate cancer ranks as the most frequently diagnosed cancer among men in the U.S. Approximately 1 in 8 men will be diagnosed with prostate cancer at some point in their lives. It is also the second most common cause of cancer-related fatalities. However, the death rate can be controlled with early diagnosis. There are various tests and biopsies that a physician can conduct to diagnose prostate cancer or other abnormalities.
In medical billing, a prostate biopsy is represented with CPT code 55700. If you are curious about its billing guidelines and the correct way to use this code for reimbursement of your services, keep reading this blog.
CPT Code 55700 – Description
The American Medical Association maintains CPT code 55700 under Incision Procedures on the Prostate codeset because it represents a prostate biopsy procedure.
The provider performs a biopsy where he takes tissue samples for microscopic examination of the prostate gland using a specialized biopsy needle or during a surgical procedure for pathological analysis. You can use this code regardless of the method employed, such as transrectal, perineal, or transurethral.
Physicians generally use this code to identify or exclude the possibility of prostate cancer, assess the characteristics of prostate irregularities, and assist in making treatment choices.
Scenarios Where CPT Code 55700 is Applicable
The following medical scenarios effectively highlight the correct usage of CPT code 55700.
Prostate Cancer
Suppose a 50-year-old obese man visits the hospital with issues while passing urine. He says that he experiences pain while passing urine, and sometimes it comes with blood. The physician attending him suspects prostate cancer, so he decides to conduct a biopsy to diagnose the cancer or any other abnormality causing the issue. He takes a tissue sample to look for malignancy. This is the gold standard to confirm the presence of prostate cancer and determine its aggressiveness. Hence, he can apply CPT code 55700 to bill his biopsy services.
Benign Prostatic Hyperplasia
Benign prostatic hyperplasia (BPH) is the most common prostate-related disease among men older than 50 years. The disease causes the prostate to enlarge. So let’s imagine a scenario where a 60-year-old man visits your practice with symptoms like uncontrollable leakage of urine and a feeling of a full bladder even after urinating. The symptoms of BPH are almost similar to those of prostate cancer, so you conduct a biopsy to rule out any chances of prostate cancer. In this scenario, where you performed a biopsy, you can apply CPT code 55700.
Prostate Lesion
Imagine a 65-year-old patient comes in with his prostate MRI reports that reveal a suspicious lesion. The physician needs the biopsy results to confirm cancer. So, he conducts a perineal biopsy (takes tissue samples from the prostate gland through the skin of the perineum) to avoid any infection in the lesion. This involves inserting a needle through the skin between the scrotum and anus. Since prostate biopsy, regardless of the approach, can be reported with CPT code 55700, the physician will use this code to bill his services.
Applicable Modifiers for CPT Code 55700
The following are the applicable modifiers with CPT code 55700. However, it is important to understand the payer’s guidelines before appending these modifiers.
Modifier 22
You can append modifier 22 when the physician performs greater services than what is typically necessary for the specified procedure. You cannot apply this modifier solely for more work. The following are the situations where you can apply modifier 22:
- If the procedural time or service is higher in intensity
- In case of increased technical complexity or the need for more mental and physical work
- If the patient’s condition is serious
Modifier 59
Modifier 59 is used to refer to a distinct procedural service. You can apply modifier 59 with CPT code 55700 if the biopsy is distinct from other services performed on the same day or if the biopsy was performed at a different site on the body. However, most insurance payers discourage using this modifier. Instead, you should apply more specific modifiers for distinct services depending on the situation, such as modifiers XE, XP, XS, or XU.
CPT Code 55700 – Billing & Reimbursement Guidelines
All medical coders and billers need to comply with the following billing and reimbursement guidelines for CPT code 55700.
Provide Supporting Documentation
Precise documentation of procedures is essential for correct coding and billing. You must be thorough with your paperwork as it will communicate essential information to the insurance payer, helping them assess the medical necessity of the procedure.
Your supporting documentation for CPT code 55700 claims should consist of:
- The number of samples taken.
- Clinical indications that support the need for a biopsy.
- The method used, e.g., transrectal, perineal, transurethral, or endoscopic.
- If using imaging guidance, such as ultrasound or MRI, indicate whether the procedure was performed in a facility or office setting.
Justify Modifier Usage
Always make sure that the use of any modifier is justified in your documentation. Your documentation must support the circumstances when you add modifiers like 22 or 59.
If you include modifier 22, you must indicate the extra work that was necessary and recorded. In order to obtain more biopsy specimens than usual, the urologist puts in a significant amount of additional time and effort. When submitting this claim, you must include in your documentation the reasons and justifications for the increased effort and the greater number of biopsies conducted.
Without compelling evidence that the medical service was significantly more difficult or time-consuming than usual, the payer will not approve additional payment for a procedure.
Be Wary of the Frequency of Biopsies
You can bill CPT code 55700 only once per session. However, the number of samples taken can vary. The code itself covers one or multiple samples. However, all the samples must be taken in one session on the same day by the same service provider.
Follow the Policies of Insurance Payers
Each payer has its own set of rules and regulations, including Medicare, Medicaid, and private insurance companies. To determine complete coverage requirements, you must read and understand their specific policies. For example, not all private insurers accept modifier 22 with code 55700. Thus, before filing a claim, you must confirm the insurance payer’s coding and billing rules.
Conclusion
Prostate biopsy is represented by CPT code 55700. Regardless of how the sample was taken, you can report this code. You must, however, exercise caution when adding modifiers and confirm coding specifications with the insurance payer in advance. Moreover, you must ensure adequate and accurate documentation to justify the medical necessity of a prostate biopsy.
If you are still unclear about the billing of CPT code 55700, we strongly advise you to acquire professional urology billing services. The experts offering these services are knowledgeable about the payers’ policies and any revisions to them. Thus, they can help you avoid losing money.
