Key takeaways from this episode

• In the office, the new transperineal codes pay roughly $230 to $240 more than their transrectal counterparts under the Medicare national rates. 55709 versus 55707 is a $239 difference, 55710 versus 55708 is $232.80, and 55712 versus 55711 is $239, and nearly all of that sits in practice expense (guides, higher-dose local anesthesia, clean prep area), not work RVUs.
• The fusion-versus-ultrasound differential is much smaller, around $70 to $78 per biopsy, so the fusion decision is a capital-equipment and volume question. Disposables barely change; what matters is how many biopsies you do and whether the net per case covers the equipment.
• Each additional targeted lesion adds about $81. The economics of fusion depend on how many biopsies you do and how many of them target more than one lesion, and the code set separates systematic-plus-targeted encounters from targeted-only encounters, so document which you did.
• Physician payment for the same biopsy is materially higher in the office than in a facility. Mark put transrectal at about $200 to $250 and transperineal in the $420 to $464 range for the office-versus-facility physician differential, so ASC or HOPD ownership (or lack of it) has to be part of the calculation.
• Nobody yet has objective data on how many targeted lesions are typical per patient, because billing did not separate lesions before January 1. Practices should project volumes from their own physicians or EHR mining until a year of data on the new codes accumulates.
• Use the free UC-Care calculator at prsnetwork.com/navigo to model biopsies by location and type, added lesions and your per-procedure costs before investing. Factor in the time value of money: office cases avoid travel, block time and downtime, and a cancellation can be backfilled with revenue-generating patients.
• Clinical decisions come first and the fee schedule keeps moving. Decide fusion versus ultrasound and transperineal versus transrectal on clinical grounds and patient tolerance, and expect 2027 modifications to the prostate biopsy codes; this year brought a 2.5 percent work-value hit, about a 5 percent bump for in-office urology procedures and roughly a 9 percent drop on the facility side.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 277, recorded February 2026, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

Setting up the question: the clinical choices come first

[00:00] Scott Painter: On this episode: the new economics of in-office prostate biopsies. Stay tuned. Welcome to episode 277 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. As mentioned in the intro, today we're going to talk about in-office prostate biopsies. What does it mean with the new codes, and how is it all shaping up? Mark, do you want to give us the general overall landscape? Then I'm sure Ray and I will have a lot of questions. Let's do it.

[01:00] Mark Painter: All right. Scott, we've talked a lot about the coding and the reimbursement rates assigned to each of the new prostate biopsy codes. So today, let's dive a little more into the economics, and the differentiation economically rather than the coding differentiation. Before we do that, we should generally acknowledge a couple of different issues on the clinical side.

Number one, there are a number of papers and lots of discussion about the benefits of fusion biopsy versus straight ultrasound biopsy. We've also got other new technologies coming down the pipeline that we're going to have to measure in the future, but we're going to focus on what's available coding-wise, and really on fusion versus ultrasound today, because we could complicate this issue even further. So that's the first piece that needs to be decided by the clinician: the value clinically of fusion biopsy versus ultrasound, and whether that's something they would like to explore. Again, this is something that's up for debate, and we're not going to play clinical referee here.

The second thing is the considerations of transperineal versus transrectal. Certainly there are discussions around the safety and efficacy of transperineal versus transrectal, which is yet another thing the clinician needs to consider in the overall targeting for prostate biopsies: which approach works better clinically? On top of that, when we start looking at the differentials of site of service, office versus ASC or HOPD, we have a third level to consider, and that's the patient comfort, or viability, of transperineal in the office setting. We certainly know that transrectal is common in the office setting. Right now, transperineal is not as common. But we do know there are folks in the marketplace performing transperineal biopsies in their office using things like local anesthesia, potentially supplemented by ProNox, or maybe not.

And of course we've got Ray with us, and he was telling us as we were talking about this beforehand that before ultrasound came into play, patients were biopsied transperineally, and the guidance was the physician trying to identify the areas within the prostate that needed to be biopsied. That's the 55705. So it's interesting that in many ways we're coming full circle on some of this, as the technology has driven things in that direction.

Clinically, we're not going to make those arguments. Those are things that are out there. The consideration of transperineal in the office, and the additional patient comfort issues you're going to have to consider, are going to be a real part of whether or not you're able to turn around and look at the economics. So you have to figure out, clinically, what are my goals, and what can I legitimately do in my office setting, based on my personnel, my comfort level, and what I'm willing to talk to my patients about? Can I navigate those things? All of those are important considerations as we run through this argument, and we're going to leave them to each of the physicians.

We're going to pivot now to just talking about the money. As we always say, the money is a piece of this. It is a consideration, and a big consideration in the market today, but it should not be the primary consideration. The primary consideration should be your goal to care for your patients in the best way possible. I want to make sure we put that disclaimer in there first, and we'll leave that to your decision.

Transperineal versus transrectal: the office payment differential

Mark: So now we're going to start looking at differentials. When I look at the Medicare national payment rates, there are a couple of things we considered when we started talking about what the argument is financially, or whether an argument can be made financially, for adding approaches to prostate biopsy in the office. Can you work with MRI fusion in your office? Can you work with transperineal? This assumes, as we've seen anecdotally and across the country with billing, that the majority of physician offices are now capable of and are performing ultrasound transrectal biopsies in the office.

So when we look at the office differentials, the first thing is transperineal versus transrectal biopsies. With the new codes we have in place, there's roughly a $230-plus differential based on approach. Comparing 55707 with 55709, we see a $239 difference between the two. 55708 versus 55710: $232.80. And 55711 and 55712: $239. So that differential in the office setting is a decent number, and it is based on equipment and the considerations. It's primarily in the practice expense value. The differentials in the work RVUs are not so much there. There's some, but there's really not a big differential in the work values. That number is primarily driven by practice expense, and that's because we do have additional expenses: guides, local anesthesia in higher doses, a clean prep area. Those were all things that went into the valuation of those particular codes. You may have to get a change in your probe so you can actually mount a transperineal guide, and you're going to have some of the disposable guides that are out there. So there are some additional costs you're going to have to navigate, the differential and the cost of goods, in your decision on whether this is something you can do, in addition to the clinical arguments we mentioned before.

Fusion versus ultrasound and the targeted-lesion add-on

Mark: Then the secondary piece we wanted to look at was the differential of fusion versus ultrasound. This number is not as big. The disposables are not really changing as much when you're talking about fusion versus ultrasound guidance. What you're talking about here is the capital equipment expenditure, how many biopsies are done, and whether the volume of services and the net for each of those services can cover the cost of the equipment. Frankly, people have been disappointed with that number, as it came out at around $70: $70.48, $78. So it's not as much in that differential between ultrasound and MRI fusion.

Now, in addition to our baseline codes, with the fusion codes we do have the ability to do additional targeted areas, targeted lesions, which adds an $81 bump for each additional targeted lesion or area. So the finances there would depend on, A, how many biopsies you have, and B, of those biopsies, how many are targeting more than one lesion, to add in that additional lesion code. That also allows for a slight bump in costs as you look at extra needles and potential sample-gathering equipment. So you may have an incremental bump in your cost, but the majority of that could, in essence, go to physician effort plus the capital equipment cost. Those are the variables you need to take into account when you start looking at the potential of bringing in fusion biopsy, and whether you want to consider changing from transrectal to transperineal. And then the final is the combination of both: adding fusion plus transperineal biopsy in your office. So those are the numbers, and I definitely threw a lot of them out there. I'm going to stop and see, did that make sense, or was it way too snaky, for lack of a better word?

Old-school transperineal biopsies and the first ultrasound coding

[12:00] Scott: No, I think that made a lot of sense, and I've got a couple of questions to follow up. But first I want to hear from Ray. I want to hear about the old-school transperineal biopsy and why that came about.

[13:00] Dr. Ray Painter: Scott, you're talking about the old, old school. This was back in the time when we didn't have PSAs. We did not have ultrasound, and normally you were biopsying a very hard lesion which was already inoperable, because if you look at the statistics, we did very few radical prostatectomies back in those days, because you could not detect the cancer early enough. But that has allowed me to look at the change in practice as time has gone on, because you may remember we worked with them when they brought the first ultrasound into the United States. That was an exciting time.

Mark: You mean when we were working on the coding for that, as we started driving those in? Yeah.

Scott: All right. Go ahead, Ray. Any comments or questions for Mark?

Ray: No, I was just... Mark talked about working on the coding. We had Medicare paying for about two-thirds of all the ultrasound before they ever had a code, which was unique back in those days.

[14:00] Mark: Yes. So a collective pat on the back for us on that one, for sure.

Ray: And the technology and its need.

Mark: That's true. It was quite the shift in the landscape.

How many targeted lesions, and what the new codes will tell us

Scott: Okay. A couple of questions for you based on your discussion, Mark. Just out of curiosity, do you know how many targeted lesions are typically done? I know it's clinician by clinician, but is there an average? Are you seeing two or more, or are you seeing a lot of onesies being billed, or do you not have that data?

[15:00] Mark: We don't really have that data. The billing until January 1 did not separate the lesions, so I don't have a good handle objectively on the number of lesions that, on average, are found in a patient. We will build that data over the next year. This is something each practice will have to rely on its physicians to accurately estimate or project, unless they've got a good EHR mining tool and everybody's documentation was really good. That's the other piece that, unfortunately, is out there. Because it didn't really affect the coding, a lot of the data we looked at talked about how many cores there were, not as much about how many targeted areas. They were not necessarily as specific in the documentation as to where the cores came from. Now, if we were to go back and look at pathology data, and that may be the real driver in all this, usually the pathology marking when they sent it in told them where those samples came from. That actually might tell us, but that doesn't mean we targeted them. So there's a disconnect in all of this. I'm sure there are studies being done, and I'm sure there are some folks who have done this, but as far as widespread data, I'm not aware of any.

Scott: I think the new codes will tell us that.

Mark: For sure. They will start to, yes.

Ray: Mark, is there any data out there to differentiate just taking a random core biopsy versus that being a targeted lesion?

[17:00] Mark: No, same thing. We didn't have those codes. From the billing standpoint, which is where we look at large-scale data, we don't have it. And then the other thing is, MRI fusion, when we really started targeting, that technology is relatively new, and I'm going to say relatively, being in the last three to five years. The secondary piece is that it wasn't as widespread in utilization because it was difficult to get paid. So we're going to see a lot more data develop on this. We have a lot of physicians who were using ultrasound machines that, from a financial standpoint, weren't as high-end, to actually do the targeting we needed. That's going to change as well. There's a lot that's changing. Obviously the use of MRI is increasing, and our clinical guideline recommendations are changing. So that number is going to evolve, or I would project it's going to evolve.

[18:00] Ray: So if you're a urologist getting ready to do an MRI fusion biopsy, and you've identified three or four areas that you specifically want to biopsy, then those would be targeted areas. And if you just took another random ten biopsies to cover everything, those would be just extra biopsies.

Mark: As you know, the codes are set up for systematic biopsies plus the first targeted lesion, or targeted lesions, as the codes are set up. So you could do a straight targeted biopsy encounter, where you're not doing a systematic biopsy, and that's a different code set, versus "I'm targeting a specific lesion and systematically pulling random samples from the rest of the prostate." The codes are going to differentiate that now, and that's what everybody needs to document.

The Navigo calculator and the office-versus-facility differential

[19:00] Scott: Yep. Okay. So looking at the economics of this, putting the clinical side in the hands of the urologist or the QHP, let's look at that. If you're trying to make this decision, and you've already made the clinical decision that you're comfortable with whatever you're comfortable with, but you're trying to figure out how this works economically in your office: one of the things we have to help you do that is a calculator. One of our hub sponsors, UC-Care, worked with us to create a calculator where you can go in and enter the number of biopsies by location and by type, add additional lesions in, and then enter the cost per procedure you're going to incur, and really look at what makes sense in your office. If you want to check out that calculator, you can go to prsnetwork.com/navigo, N-A-V-I-G-O. That's the UC-Care product, the MRI fusion product they have for in-office use. You can go there and download the calculator and play with it. There are a lot of different numbers out there, and Mark threw a bunch out, but you can put those in and check out what makes sense in your practice. All right, Ray, any other questions for Mark?

Ray: No.

Scott: Mark, anything to add?

[21:00] Mark: I think we've given enough caveats and everything else to confuse everybody pretty well. The other piece I'll add is that in this episode we did not focus on ASC payment rates, for those people who own ASCs, or the HOPD. We really focused on those differentials. So the last one I do want to throw into the mix is the physician payment differential of in-office versus a facility setting. That's the other margin you're working with, and we did not talk about that one. That one is significant. Transrectal is about $200 to $250, and transperineal is in the $420 to $464 range, when we look at those differentials. So your ownership or lack of ownership on the facility side, and we'll have a separate episode talking about how these numbers work in the facility setting, is the other number you need to consider. The first piece of this was focused on MRI versus ultrasound and transperineal versus transrectal. The last piece, and a very important piece you need to consider, is the fees the physician group gets and whether that feasibility is there financially.

And then the last thing, which we mentioned a little when we were talking about clinical but didn't really focus on, is the time value of money. That's the other part of this. For years we've talked about the fact that, unfortunately, surgery is an expensive hobby. The reimbursements have been flat, and of course we took a two and a half percent hit on all the procedures we do in the hospital. We took them in the office as well, but that two and a half percent was on the work value. The practice expense value went up a little this year, and we saw that in the changes. We know there's about a 5 percent bump for urology coming for in-office procedures, versus a 9 percent drop, because we saw a significant drop in the facility practice expense that was added this year because of all of our hospital-employed physicians out there. Whether that trend continues is going to be interesting, and certainly as we see more and more physicians go into hospital employment, that may be a number that bumps again on the practice expense side. We already know that CMS is looking at whether they can drop the work RVUs again for efficiency for physicians in that setting. Again, that impacts both, but the relative fee, because of those different applications of the practice expense value, gives the office an advantage.

It's still not where we need it to be. Anybody who's heard me speaking recently, and heard us talk about the changes in the Medicare fee schedule this year and last year and the year before, knows my belief is that currently this system is not well built to handle the amount of technology we have in the market and the ability to provide so many services in the office setting. The practice expense, the disposables, all those things, it's not really where it needs to be. We should essentially be getting paid more in the office for all that we do, and this is something that hopefully, over the next few years, we're going to address. So that's the other thing we look at in the trends. Yes, we've got this year's numbers, but what's going to happen next year? Are we going to see that differential widen on the physician payment side? That's the last piece of this puzzle, and it's a big one: what is that differential on the payment side?

And then, of course, the other part, with all of urology overloaded and such a shortage of urologists: how can you save time to treat more folks? Is the office-based procedure, and in particular here the prostate biopsy, something where the overall investment in new technology, and potentially in transperineal to look toward the future, is worth the value? Can it be covered financially enough that it makes sense? That's going to be the bigger question: the choice between the office and the ASC, and whether you're willing to give up your time. This is where I hear a lot of folks, and one of the reasons they're sticking with ultrasound biopsies right now is that investment in new equipment and new approaches, and whether your practice can handle it. That's the other piece that really needs to be considered, and it falls into time. With hospitals, and some of the ASCs you don't own, you have to focus on block time. You've really got to manage your time well, your scheduling, deal with cancellations, and what can you do in addition to the services you're providing? Whereas in the office, if somebody cancels on you, typically you've got an easy way to backfill that with patients who need your care, and the potential to generate revenue. So there's more to it than that first part of the discussion, and I think that's actually the bigger consideration overall: whether an investment in this new technology now, with the current reimbursement, actually makes sense, or makes enough sense to plan for the future, as we really start to drive more and more healthcare into the office and out of the ASC and the hospital, or at least out of the HOPD and into the ASC with physician participation in the reimbursement of the ASC through partial or total ownership.

Sponsors and final thoughts

[28:00] Scott: That's a great point, Mark. The travel time to the ASC or the HOPD, the waiting in between procedures and the downtime all have to be considered if you're comparing in-office procedures, where you have control over the schedule, versus a facility setting. That is a huge consideration that needs to be part of your calculation. All right, let's wrap this episode up. 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. We also want to give a special thanks to UC-Care, one of our hub partners. You can check out their information on our hub pages: go to prsnetwork.com/urologyhub for the overall hub pages, or if you want to go directly to the UC-Care page, go to prsnetwork.com/navigo, N-A-V-I-G-O. We want to thank them for their support of this episode as well. All right, let's get some final thoughts. Mark, how about some final thoughts?

Mark: First, I'd like to apologize to those of you who listened to this podcast while driving. We threw out a lot of numbers and asked you to mentally calculate a lot of things. Sorry about that. But it is something I think many of you have mulled over in your head, and hopefully we gave you some things to think about. Again, the tools on the hub, I think, are going to be helpful. And I do encourage all of you, as always, to look toward the future.

It is hard to predict. It really is. We've seen so many shifts, and we're going to see more, because we already know the codes for prostate biopsy are going to see some modifications for 2027. We'll see reimbursements changing again. So we're basing a lot of our projections, and I'm basing a lot of what I'm looking at, on what I know and the trends that are out there. Hopefully this gives everyone a little different window into ways to look at things. And then again, that final reminder: it is about patient care. I know that you all know that, but I feel like I need to say it more than anybody, because I'm talking about money so much that we sometimes forget about the patient care in our discussion. So understand your own capabilities, and your patients' capabilities to receive care, before driving any of these things. It might be worth making sure you can do a transperineal, if you're thinking about transperineal in the office, and how that works. Talk to people in the market who are doing this. It's going to take a village. Leverage your friends, leverage your colleagues, leverage your experts across the board. And if you need some additional advice, generally, on what's going on, let us know. We're here to help. Ray, final thoughts?

[32:00] Ray: That was a good discussion, and if I got it right, Mark, it sounds like the doc needs to take a look at the clinical side, all the statistics, figure out what they think is best for their patient, both technology and approach, and then use the money guide and all the work that you and Scott have done to make it easier to figure out whether they can afford to provide it or not. Is that sort of the summary of what you've talked about?

Mark: That's a pretty good summary.

Ray: Good luck, everybody.

Scott: Well said. That's all we have for today's episode. Thank you all for listening. Take us out, Ray.

Ray: Happy coding.

 PRS Coding and Reimbursement Hub

Access the Hub

Free In-Office Prostate Biopsy Calculator (Suppoted by UC-Care)

Download Now

PRS Coding Courses

For Urologist

For APPs

For Coders, Billers, and Admins