Key takeaways from this episode

• All of the new 2026 prostate biopsy codes, 55707 through 55714, carry a zero-day global. The one exception is add-on code 55715, which is ZZZ and follows the global of its base code.
• The new codes are driven by approach, guidance and number of targeted lesions, not by the number of cores. A transrectal ultrasound-guided biopsy is 55707 whether it is a six-core sextant, a 12-core sextant, or a sextant plus two lesions with 16 cores in total.
• For MRI fusion transrectal biopsy, 55708 covers the systematic sampling plus the first targeted lesion, and 55715 is added once for each additional lesion. Two lesions plus a sextant is 55708 plus 55715 x1; three lesions is 55708 plus 55715 x2. Billing 55715 x11 for 12 cores is incorrect.
• Use 55711 for a transrectal fusion biopsy that targets a lesion only, with no systematic sampling. Document the target as a "lesion" or "area of suspicion," since those are the words the CPT descriptors use. Transperineal codes 55709, 55710 and 55712 follow the same rules with a different approach.
• Fusion codes require the MRI to be fused on a separate workstation; a cognitive MRI review with ultrasound targeting is still 55707. That is how the CPT instructional language is written for 2026.
• The in-bore codes 55713 and 55714 may not be accepted by payers for the low-field ProMaxo system, because ProMaxo's own FDA literature distinguishes low-field from in-bore. Ask the payer first whether ProMaxo qualifies; if no answer comes, the cautious options are 55713 with modifier 52 and a box 19 note ("MRI-guided biopsy using low-field ProMaxo system") or an unlisted code crosswalked to the 55713 value.
• 55713 and 55714 are the only new biopsy codes with a higher facility fee in the ASC and HOPD, and a higher office fee as well. That extra payment reflects MRI equipment cost, which is why payers may push non-in-bore systems to a lower-paying code.
• Expect payer interpretations and coverage rules to roll out over the next six to 12 months, with likely code revisions for 2027. As with 55706 for template saturation biopsy, different payers had different rules under the old codes, so watch each payer's guidance.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 269, recorded December 2025, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

Do all the new prostate biopsy codes have a zero-day global?

[00:00] Scott Painter: On this episode: questions about the new prostate biopsy codes. Stay tuned. Welcome to episode 269 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-hosts Mark Painter and Dr. Ray Painter. On today's episode we're going to answer a few questions that have come in regarding the prostate biopsy codes, the new codes that are coming out in 2026. So let's dive right in, and then, Mark, I think you're going to give some overall insight into the codes. First question: "There are new prostate biopsy codes for 2026," and he goes on and lists them all, 55707, 55708, 55709, 55710, 55711, 55712, 55713, 55714 and 55715. "Do all of them have a zero-day global?" All right, what have you got, Mark?

[01:00] Mark Painter: So the answer is zero is correct, with the one exception of 55715, which as an add-on code is a ZZZ, which means, of course, as an add-on code, it's driven by the base code. So yes, all of these codes have a zero-day global.

Scott: All right. Let's move on to the next.

Mark: Probably the shortest answer I've given on the podcast.

Scott: I know. There's no gray area or anything.

Mark: Yes, I know.

Which new code fits an MRI-guided biopsy on the ProMaxo system?

Scott: All right, next question. "I wanted your opinion on which new prostate biopsy CPT code is the best choice when the provider uses the ProMaxo system." They go ahead and list an operative note, but we're not going to read that, because I think you can answer that without the op note. Is that correct, Mark?

Mark: Yeah, I think I can. The issue we've got, and I can understand why the question is coming in, is CPT code 55713, which is biopsy, prostate, in-bore CT or MRI guided, sextant, with biopsy of additional targeted lesions, first targeted lesion, and then 55714, which is biopsy, prostate, in-bore CT or MRI guided, targeted lesion only, first targeted lesion. The issue we've got is that first part, "in-bore." The ProMaxo is a low-field MRI. It's really an interesting system, and certainly as we've looked at it, it could open up MRI-guided biopsies, and MRIs actually, in a much less expensive environment. It doesn't require the same type of shielding and reconstruction that a standard high-field bore MRI does. So it's got some real potential utility in places where we can't economically support a larger in-bore high-field group.

Now, the issue is that these low-field systems are not technically in-bore. As I read through several of the documents they used as part of their FDA justification, they actually compare in-bore to low-field as separate issues, and that kind of guidance within the literature may lead to some payers interpreting the CPT code as not applicable to the ProMaxo. But certainly the intent, I think, of an MRI-guided biopsy, and the fact that we're using the MRI imaging to actually guide the biopsy without a previously obtained MRI and fusion, would fit the spirit of the code, the 55713 and the 55714, using the ProMaxo.

So what we've really got here is one of those strange potential interpretations of the payer. It certainly walks like a duck, it acts like a duck; the test fits from that side. But that language of in-bore, and some of the documentation that came out with the studies originally, may have put a roadblock in place for some of the payers. So right now I am going to state that we need to check with the payers for the use of that code for the ProMaxo system or the low-field MRIs. We're also going to lean on trying to get a little more guidance from the AUA and the developers of the codes to find out what the intention truly was of these particular codes. It really should be available there. But in the end it does have that interpretation component that we have to issue a caution for. Really take a look at what your payers are going to work with. They may drive you to a different code.

The good news on this, I think, is that we do have established values for these in-bore biopsies, and if we're using maybe an unlisted code for this, we now have a crosswalk to help set up the actual reimbursement if the payers direct you not to use this code for the ProMaxo. So I think it's a step in the right direction. I would have liked to have seen the in-bore removed from the codes, if I had my druthers. But I do think it provides some interesting guidance for us to truly leverage the ProMaxo system in multiple settings, even if we can't use this code directly.

Scott: I think it's also interesting that those two codes, the 55713 and the 55714, the in-bore codes, do have a higher facility fee in the ASC and the HOPD. Those are the only two codes that do have a higher fee in those settings.

Mark: It does. And of course it has a higher fee in the office, and that is part of that facility component. That's the one caution I have: it really seems to point to the fact that they're looking at the overall cost of the MRI and its depreciation and its indirect and variable direct costs that are part of the procedure. That's why that in-bore could be used to try to navigate those into a lower code. Or the other option might be that we look at a 52 modifier to say, okay, it wasn't in-bore, but it was still MRI guided. So I do think there are options as we look at this, and certainly with the baseline we have with that in-bore code, we've got a much more navigable process to obtaining reimbursement for that particular procedure. But I would check with my payer, and I would use caution in making sure that I really have the understanding from the payer of what I'm doing relative to the CPT code and how they're interpreting that CPT code.

What does "in-bore" actually mean?

Scott: Ray, thoughts, questions?

Dr. Ray Painter: Well, Mark, I don't usually ask questions that are more detailed than what you said, but I have a question. What is the definition of in-bore?

Mark: That is a good question. Essentially, as you know, both the CT and the MRI typically are closed systems, where they have an imaging tool that surrounds the patient. They go into a tube or a bore, and that imaging is driven from a 360, if you will, around the patient. So they have that as a typical, maybe not typical, let's go with standard, process. Now, the ProMaxo system and the low-field systems actually don't put the patient in a tube or a bore. Those systems can be placed bedside. And there are other ones coming out. We have open MRIs, we have new things coming out with MRIs built into a table, so there's not a real bore, if you will, or tube in which the patient is when the imaging is acquired. So that's the differential that I would see in the definition.

[10:00] Ray: So the in-bore is actually putting the patient in that tube that you usually have to go in when you have an MRI.

Mark: That's the way I interpret the CPT code. And that's kind of the way the studies came in as they labeled those: they were specific in that the high-field MRIs typically were in-bore, whereas for the low-field they did not mention bore, because they were not inside the machine, if you will, the tube that actually collects the images. So this is one of those areas where you have mostly lay people interpreting the CPT code, and of course a lot of the payers are going to want to take advantage of the fact that the portable systems are not as expensive to obtain or maintain.

Ray: Scott, read the definition one more time of the 13.

Scott: 55713 is biopsy, prostate, in-bore CT or MRI guided, i.e., sextant, with biopsy of additional targeted lesion or lesions, first targeted lesion.

Ray: Hmm. Well, that's interesting, because for a CT scan you don't really go in-bore either, do you?

Mark: Many of the CT scanners are full. You can get an open CT, so there are those that are open there too. And a more traditional open MRI or open CT are bigger.

Ray: Wait a minute, Mark. Let's read that closer. It's an in-bore CT, or MRI guided.

Scott: It doesn't say in-bore MRI. Interesting. I can see that interpretation. You don't think the in-bore applies to both?

Ray: Nope. There's a hyphen between the CT and the MRI. So maybe...

Mark: You're saying that CT is not guided.

Ray: Good, good. Maybe I misread that, because it's a hyphen, not a comma, after the CT. So I probably had a wrong interpretation. Well, with that in-bore being there, and this is not an in-bore machine, wouldn't you think the 52 would probably be the best answer?

Mark: Honestly, I think 52 is a reasonable answer. Again, what we're talking about is how the payers interpret this. They may want to say, look, it's MRI guided, so let's use the MRI guided. That works.

Ray: Yep.

Mark: We don't know how detailed those interpretations are going to be, or what the restrictions are going to be. That's one of the disadvantages of a new code like this: how is the code interpreted? How strict are they going to be on this? They may say, fine, it's MRI guided, and the in-bore doesn't really make that much of a difference. It's an interpretation thing.

Should you test the payer, or ask first?

[14:00] Ray: All right. Now, if I'm just a practicing urologist and I've got the ProMaxo system, and I read this code, would I be fraudulent in billing the 55713 without a 52 or something, to test the payer? Or do I need to go to the payer first and see what they say?

Mark: Well, you know what I'm going to say. You want to go to the payer first and double-check what the requirements are, because you've got two things that you're always up against. We've got the reimbursement level, and we also have the coverage that's set up. Are there additional restrictions on when an MRI-guided biopsy can be done? That's a question I would ask. And I would also want to know, do they consider a ProMaxo system eligible for 55713? I would want all of those answers before I tried.

Now, I would also not be surprised if I didn't get an answer. You don't have the sophistication in the front end to actually give you those answers. So it's going to be a question you ask, with probably an answer you're not going to get, and you're going to have to push a little bit. In the end, if you were to put it out there with a 52 modifier to indicate that this wasn't truly in-bore, or you were to bill it as an unlisted code, would that be the safest? Probably, until you got a directive to essentially use this code from the payer. But it's questionable. It really is. To me, it falls into that gray area. In this particular sense I have to say take the most restrictive of interpretations and say, yeah, if somebody went to the mat saying in-bore means in-bore, it's part of the code, I'm going to deny this claim, then they would deny it.

Now, your question was, is it fraudulent? That's a tougher question. That one's an interpretation that gets left to the court. From a fraud standpoint, did you intentionally tell the payer you are doing something that really isn't described by this code? I could see that going either way. It's the lawyers. So again, I'm recommending caution.

Ray: I think you've got good advice. What I hear is that I should ping the payer and try to get their answer, and if not, charge it with a 52 to be cautious, put a full explanation of the fact that it is an MRI, and let them interpret it.

Mark: You could use box 19 to say "MRI-guided biopsy using low-field ProMaxo system." You could do that. You could also do that with an unlisted code, and either would be, from a purely coding standpoint, a correct approach.

Scott: All right. Let's move on to the final question.

Mark: I probably should have said a reasonable approach. Who knows what's correct?

Scott: Yes, that does make sense.

Ray: All right, let's move on. And it might keep you from having a huge payback too.

Transrectal biopsies: cores don't matter, targets do

[18:00] Scott: Move on to the final question. This came in from Rachel. "Hello, Mark. We are hoping to enlist your assistance in understanding the changes coming in 2026 for the prostate biopsy. According to the CPT book, CPT 55700 is going away and will be replaced with other CPT codes. The biopsies in our practice are performed via transrectal. The CPTs it appears we will be using are CPT 55707 for the ultrasound, non-MRI-guided biopsy and 55708 for the ultrasound, MRI guided. My question is, since it appears CPT 55708 is for the first targeted lesion, can we include CPT 55715 for each additional lesion? Meaning, if the provider performs the biopsy on 12 cores, can we bill CPT 55708 times one and 55715 times 11? Is this correct?" All right, what advice do you have for Rachel?

Mark: Rachel, unfortunately we've got to separate these, and your question is one that I'm getting from a lot of people. It really goes back to the way these codes were developed. They did take into account 55700, which basically was biopsy or biopsies, any method. Essentially, these codes, if you read through the instructional portion of the CPT manual, are not based on the number of cores that are taken. That does not affect the coding. What really affects the coding is the approach, the guidance and the targeting that is being done throughout the biopsy for that particular patient.

If you and I look at these things in pairs, it sounds like you're doing everything transrectal, so you actually have three different codes, which blows the lid off my pair thing. But anyway, there is a straight ultrasound-guided transrectal biopsy. That code does state that if you're using an ultrasound-guided biopsy, it really doesn't matter how many cores you're taking, nor does it matter how many targets you're looking for. So you could do a sextant only with six cores. You could do a sextant with 12 cores. You could do a sextant with 12 cores and a lesion with two cores, giving you 14 total cores. Or we could go even further and say you do a sextant with 12 cores and two different lesions with two cores each, giving you a total of 16 cores. All of that would fit under the single code of 55707, because it doesn't matter how many cores you're taking. Unfortunately, the way they set up the ultrasound-guided codes, it does not matter how many different targets you are going for. Sextant plus lesions, just a lesion, just a sextant: it all falls under that 55707 for the transrectal.

With the MRI fusion, remember that the way the CPT manual is written, the MRI fusion actually needs to be done on a separate workstation, so we cannot, at least based on the CPT, look at a cognitive MRI. If the physician is looking at an MRI, but it wasn't fused in the machine, and is using an ultrasound to get the specific areas he or she is trying to target, we'd still use the 55707 for that transrectal.

For the fusion, where we did fuse it on the machine, we do have some targeting considerations. If we do a sextant, whether you did one core, two cores, three cores or four cores for each sextant, typically the 55708 would be used. Now, that one also says first targeted lesion, so I think the underlying assumption here is that you would really only use MRI fusion guidance if you had at least one area of suspicion, or a lesion, that you were specifically targeting in addition to the standard systematic sampling of the prostate, like a sextant biopsy. So that would be 55708: one lesion plus the sextant, or plus the systematic sampling around the prostate. If there were two areas of suspicion or lesions in the prostate, then you would add the 55715 for that second lesion that was targeted. Again, it doesn't matter how many cores you're taking; it's about the targets. If you targeted a third lesion in that same encounter, then you would use 55715 times two, because the first lesion is included in the base code, the 55708, as well as the systematic targeting of the remainder of the prostate, and then you would use 55715 for the second and for the third. So you could add two units of 55715.

And then the one you didn't mention, but is still transrectal, is the 55711. This is for those cases where you've actually done the fusion, you are still going transrectal, but you are not doing a systematic biopsy of the prostate. You're really only taking biopsies from a targeted area or a targeted lesion. "Area of suspicion," "lesion," those are the key words you're looking for, and I would say, given the way the CPT codes are written, you want to mention that as a lesion in your documentation. That's really the way I've seen most of the templates set up. So if it's one lesion only, it's 55711, and then, of course, for each additional lesion after the first, you would add 55715 for each additional targeted area.

Hopefully that helps with that side of the equation. And then you've got the same rules that apply to transperineal. The 55709, the 55710 and the 55712 are essentially the approach changes. Again, it doesn't matter the cores. It's about the targets, and whether or not you fused the MRI on the separate workstation, that differentiates those codes.

Scott: Ray, comments, questions?

[26:00] Ray: Nope. None.

Sponsor and final thoughts: expect payer interpretations to follow

Scott: I think that was a good explanation. Let's go ahead and wind that up. Hopefully, Rachel, that answered your question. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com/prsnetwork for specials for our listening audience. All right, let's get some final thoughts on today's episode. Mark, can you summarize it all up and give us a final thought on these new codes?

Mark: Right now we are giving interpretations of these new codes based on the verbiage in CPT. As we know, that is the first step, the foundational approach that we're going to use for coding the services we provide for our patients. But we also have, layered on top of that, all of the interpretations from the various payers, from Medicare to your commercials. So we're probably going to see those roll out as people start to use the codes. Over the next six months we'll probably get more guidance, and we'll be talking about these codes again. In the end, it's kind of interesting that we use the word guidance for these guidance codes, but that is the way the system works.

And then the last thing we have to consider, relative to the CPT codes and the interpretation of those codes, is where coverage is going to land. In the past, when we just had 55700, and we had the finger-guided biopsy, 55705, and then the 55706, which was the saturation biopsy, and that code still exists, we found different payers had different rules as to whether or not 55706 could be used for the stereotactic template-guided saturation biopsy. So we're going to see interpretations of the codes on the reimbursement side, and then on top of that, we're most likely going to see some guidance over the next six to 12 months relative to coverage. We have the reimbursement for each of those codes, and then we are probably going to see these codes change a little bit for 2027, so we'll get to learn them all over again. But this is what we're starting with for '26, and it will require us to watch the payers and their interpretations, and then their coverage on top of those codes.

Scott: Ray, final thoughts?

[29:00] Ray: Well, Mark, I want to commend you for digging deep, because as you heard in the discussion, Mark's interpretation, particularly in the discussion of ProMaxo, included not only the CPT definition and how you interpret it, but also digging back and taking a look at the intent of the code, and the intent is insinuated by payment, et cetera, et cetera. And again, giving advice that keeps everybody safe but gets them paid as much as they could.

Mark: Thank you.

Scott: All right. Well, that's all we have for today's episode. I want to remind you that the Urology Advanced Coding and Reimbursement Seminar in New Orleans is going to be January 30th and 31st. Registration is open. You can go to prsnetwork.com; right there on the homepage is a button to register for the seminar, and it'll give you all the information and pricing. We'd love to see you there. We had a great seminar, as we've talked about on the podcast, in December in Las Vegas, and we are expecting an equally great seminar in New Orleans. That's all we have for today. Thank you all for listening. Take us out, Ray.

Ray: Happy coding.

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