Key takeaways from this episode

• 55706 is defined by stereotactic template guidance, not by the number of cores. The documentation should show a 3D grid map of the prostate, a pre-planned template of every biopsy site laid out before the transperineal procedure, and a procedure that follows that map; using a plastic or external needle guide on the ultrasound probe does not qualify.
• Saturation still implies sampling every portion of the prostate. CPT sets no core count, but with the new systematic and targeted transperineal codes the window for calling a partial-gland biopsy a saturation biopsy has narrowed, and payers may not accept it.
• Check payer coverage policies for 55706, because some set a core-count floor. Several payers require at least 20 cores (slightly above three per sextant), and some require as many as 30, even though CPT itself is silent.
• Without a pre-planned 3D template, the ultrasound-guided transperineal biopsy code 55709 is the fallback. 55706 has no office-based physician fee (about $203.41 in the ASC/HOPD nationally), while 55709 pays about $581.84 in the office and about $163 in the facility; the ASC facility rate is the same for both at about $1,723.02.
• The decision to perform diagnostic cystoscopy remains a moderate-risk MDM element. Diagnostic endoscopy was listed as moderate on the AMA table of risk that the current MDM matrix was built from, the AUA Coding and Reimbursement Committee agreed on moderate, and the CPT guidelines base risk on the usual behavior of physicians in the same specialty.
• You do not have to list infection, trauma and other risk factors in every cysto note to support moderate risk. The E/M examples in the CPT risk table are examples only, so the specialty's standard of care carries the risk level for billing purposes.
• If you template risk-and-benefit language for medical-legal protection, put it under shared decision making, not in the assessment and plan. That documentation can still support the risk level, but it does not need to appear in both places.
• Interpretation has to be balanced with intent. Payers get the final say, and with AI and computer-assisted coding enforcing rules at a micro level, stick with the generally accepted reading of a code rather than nibbling at the edges.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 283, recorded April 2026, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

Saturation biopsy question: what 55706 requires

[00:00] Scott Painter: On this episode: stereotactic saturation biopsy clarification, and cysto, is it a moderate risk? Stay tuned. Welcome to episode 283 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. Let's get started. We had a couple of questions come in that we wanted to cover. Again, with the prostate biopsies, with the new codes and all the things happening, everybody's trying to figure this out.

We had a question come in about code 55706. I'm going to read the question and then I'm going to have Mark read the definition of 55706 so we can see if we can't answer this and make it a little bit more clear. The question is: I have a provider that thinks some of the prostate biopsies he performs should be coded using 55706 for a saturation biopsy. The coding team feels that the documentation does not support this code. The provider uses the PrecisionPoint access system and refers to this as a stereotactic template, and feels that the number of samples taken is not a factor. I have a sample of his note that is being coded using 55706, and we'd like to know if this is correct. Thank you.

[01:39] Mark Painter: All right. First, we are not going to dive into the actual note for this procedure. We're going to talk about this on a broader scale. The definition of 55706 is: biopsy, prostate, needle, transperineal, stereotactic template guided saturation sampling, including image guidance. That's where we're going to start for all of this. Some of the key things here: obviously we've got a prostatic needle biopsy and it's transperineal. We've got a few of those now that we've got all the new codes. We have multiple transperineal prostate biopsies, including ultrasound guided, fusion guided and MRI guided, as well as targeted versus targeted plus a systematic biopsy of the prostate. So we've got a lot of options out there now that we didn't have prior. Although this code existed prior, it was in contrast to only our 55700 in the past, really, and the 55705. So we've got many more options than we've had in the past.

I think we should start with what really differentiates this code from every other code, and that's the stereotactic template guided saturation sampling. None of our other codes talk about saturation, and none of the other codes talk about stereotactic template. Let's start with the stereotactic side of this. Stereotactic template biopsies really require that you've done a 3D grid map of the prostate and pre-programmed or pre-mapped the sites from which you are going to take your samples. So you're not necessarily targeting any lesions. You're actually using this 3D map to determine how to best take samples from the prostate in what you would consider a saturation, or the ability to sample all portions of the prostate.

Now, the code does not have any specific reference to how many cores are included in a saturation biopsy. But it does imply that you are sampling across the entire prostate to get tissue from all areas of the prostate. And that would include, typically, in most people's minds, more than just one or two or three samples from each area of the prostate. That's where we get into the variability of saturation and where it is. We do have a number of payers who have established coverage guidance for this code, and some of those payers have set a floor for the number of biopsies that are required for a saturation biopsy. Again, not part of the CPT code, but part of the coverage from that payer, and something that has to be considered when you have contracts with those various payers. Some payers have set the number of cores as a floor at 20, slightly above 18, so slightly above three per sextant area within the prostate, and some have set it as high as 30. So you have to pay attention to where those definitions are in relation to the saturation biopsy.

But everyone is looking at the first part of this, which is the stereotactic template guidance. That, to me, is the most important part of documentation for the 55706. It should be clear that a 3D grid map was made of the prostate, and a template of where all the biopsies were going to be taken should be laid out in a plan prior to actually proceeding with the transperineal biopsy procedure. So I would look for documentation that supported that 3D map, the guidance from the template laid out over the patient's prostate, and then a procedure which follows that map and the overall templating that was developed in the planning stage for that stereotactic template guidance. To me, those are the most important parts of this. And I agree it's not about the number of samples in an absolute number, but in a conceptual number it is going to require that every portion of the prostate is biopsied to provide a representative saturation biopsy to meet this code.

The fallback code and the reimbursement difference

[07:41] Scott: So what's the other code they would use if they weren't going to use the 55706 in a scenario like this? Because it's not transrectal, it's transperineal, and it doesn't sound like they're using MRI fusion or any other guidance. So that would fall back to the 55709?

[08:14] Mark: 55709 would be the ultrasound guided biopsy. That would probably be the fallback here. If you didn't have a 3D template ahead of time, if you basically had a pattern that you are considering to take samples throughout the prostate, and you go ahead and use the ultrasound and guide your transperineal biopsy, even with one of those little plastic guides or one of the external guides attached to your ultrasound probe, that's not really a template that you've preplanned. You're essentially going through a plastic guide that guides you into the different parts of the prostate from which you want to take the samples. So that's much more of a cognitive issue. It is a plan, but it isn't a 3D stereotactic template, which is what is required for the 55706.

[09:33] Scott: And what's the difference in reimbursement between the 06 and the 09? Just out of curiosity, what are we looking at?

[09:42] Mark: 06, you were right, there is no office-based stereotactic guided fee. It was really meant to be in the procedure room or the ASC. You may remember this code actually came into being when there was a release of a new device that programmed in the 3D stereotactic templating, and it was really designed for the ASC. So the physician payment is $203.41 in the ASC or the HOPD at a national level. The ASC gets a payment of $1,723.02, again using national numbers. The 55709, on the other hand, does have an office-based payment, which is $581.84, and then a facility fee payment of $163. The ASC gets the same payment either way; the ASC or facility rate is the same for both codes at $1,723.02. So there is a difference in the 55709 in what it's paid in the ASC of $40 or so for the saturation biopsy, the template guided, versus the standard ultrasound guided. And then of course the ultrasound guided transperineal biopsy has a payment in the office of $581.84, whereas there is no differentiated reimbursement for the 55706.

Does saturation have to mean the entire prostate?

[11:35] Scott: Comments, questions?

[11:36] Dr. Ray Painter: Yeah, Mark, back to the basic discussion of what 55706 is. Refresh my memory. If we look at the definition, it just says biopsy, prostate, needle, stereotactic. It doesn't say anything about total prostate, entire prostate. Did we get the definition that it had to be the entire prostate by the stereotactic template guide? Or could you do a saturation biopsy of, say, the right lobe?

[12:19] Mark: That's a good question, and one that is not clearly set up in the actual description verbiage. So that is a good point. We did talk about that argument at some point in time prior to the introduction of the new codes. I do think, though, that we've got a little bit more to navigate with the new codes that have differentiation and definition around systematic or sextant biopsies and targeted lesion biopsies. That puts a little more emphasis on the saturation being potentially more geared towards the full prostate, and that's where we see the coverage issues. But I agree with you that there isn't anything in there that specifically says saturation of the prostate. I think it's more implied than anything else, and certainly that's where we're seeing that coverage interpretation being made by the payers. So it's going to be important to understand, one, what is the overall goal you're trying to deal with, and is it stereotactic in 3D as the first part of it? I think you've got some wiggle room on where the saturation needs to be taken, but again, I would encourage you to look at where the coverage guidance is in place for those payers for which you're providing this service for that patient.

[14:08] Ray: Yes. And in thinking about it, wasn't this code put in because of a specific procedure that was being performed and had been described, and didn't that sort of include the entire prostate?

[14:26] Mark: That was the original. The best thing to look at would be that the original application was based on a specific procedure, and really a specific piece of equipment that that procedure code was developed around. But as we know, there are no device-specific procedure codes; they are procedure specific. So of course that's where the interpretation comes in for all of this.

[15:04] Ray: Yeah. There is no specific CPT code. It's your interpretation of what really fits.

Interpretation, intent and the scrutiny on the edges

[15:12] Mark: Yeah. And again, the piece of this is, and we now see this quite frequently in interpretations of lots of rules, incident-to, saturation biopsies, and our next topic when we talk about E/M risk values, there's absolutely an interpretive component in all of this. Although there are valid arguments to nibble at the edges, and a lot of very smart physicians are out there figuring out how to nibble at the edges, the reality is we've got to really function within the spirit of the guidelines and the codes as much as possible.

It's a tough market right now, for sure. We're not seeing the reimbursement bumps that we really should based on the costs that are there, so everybody's feeling a bit of a pinch. But I will let you know, and we talked about this in the last couple of podcasts, the scrutiny that is now being placed on medical records and on fraud and abuse is really focused on trimming those edges as much as possible, and we don't want to encourage more regulation by abusing the system. We need to function well within it, get paid for what we really do, but remember what the overall purpose of these codes is and where they fit within the marketplace. It's a fine line that everybody's walking.

[17:12] Ray: Well, I didn't mean to cloud the issue with my question, but we have to keep in mind that if we see different ability to interpret, the payers have that same capability. So the bottom line on the 55706: we still think it should be the entire prostate, and we're concerned that some payers might interpret it that way. There is an argument that you could go partially, but payers may not agree with you.

[17:47] Mark: Yeah. And again, the first part of that, the stereotactic template guided, is the key on all of this. And as you mentioned, the overall belief is that a saturation biopsy really is about the entire prostate, especially with the new codes. I think we had a little more wiggle room when we didn't have the new codes that included sextant biopsies and targeted lesions and systematic biopsies. So I think we've got a little bit more to consider, and maybe a smaller window to consider relative to saturation, as CPT has evolved.

[18:33] Scott: Yes. A lot more lanes to choose.

[18:36] Mark: Yes.

Is the decision for diagnostic cystoscopy moderate risk?

[18:38] Scott: All right. Let's move on to our next topic. We got a question that came in from a urologist, and he says: Hi everybody, I have an E/M question for the team. It's been said by multiple urology coding experts before that the decision to proceed with diagnostic cystoscopy is a moderate risk decision. However, the E/M grid from CMS/AMA seems to suggest that if you don't identify specific risk factors in the note, then it might be more accurately described as minor surgery without risk factors, and thus low risk decision making. Can you elaborate on this a bit? I'm really hoping to not have to add fluff to the note about possible risk factors for every patient's cystoscopy pre-op discussion. Come to think of it, I can't think of a higher yield question for the average urologist in the trenches. Thanks again, as always. All right, Mark, what do you got?

[19:46] Mark: You may recall, and this is going back a few years to the advent of the new E/M guidelines that were based solely on medical decision making, that when the new MDM matrix was developed, the one thing the AMA did not throw out from the old guidelines was the table of risk. And you may remember that the table of risk in the old rules considered diagnostic endoscopy as a moderate risk procedure. Since that was the basis for the design of the new E/M documentation guidelines, we, along with other experts in the field, I think rightfully crosswalked the MDM risk level of moderate to endoscopy codes, diagnostic endoscopy, of which cystoscopy is one.

The current AMA CPT risk table says moderate risk of morbidity from additional diagnostic testing or treatment. That is the solid piece of this. The list of things underneath that are considered examples only: prescription drug management; decision regarding minor surgery with identified patient or procedure risk factors; decision regarding elective major surgery without identified patient or procedure risk factors; and the last one is diagnosis or treatment significantly limited by social determinants of health. So they didn't specifically include diagnostic endoscopy. I should note that the definition of low is a low risk of morbidity from additional diagnostic testing or treatment, without any examples listed in the risk table in CPT. So they didn't actually remove it, and it was specifically on the risk table previously published. Therefore, cysto, or diagnostic endoscopy, still, in our opinion and that of many of the other experts the questioner included, fits in that moderate risk factor.

Now, with every procedure, in today's lawsuit-happy environment, you should probably make sure that you are discussing the risks and benefits of a procedure, and templated into your medical record should be all the potential complications that are out there. So you've got a little bit of a balance there. But from my side of the equation, looking at this again, we feel we're on very solid ground from the risk table that previously existed and the development of these guidelines that a diagnostic endoscopy is moderate risk, and there are risks to the patient from the procedure that are greater than other ones. Ultimately, the design of the AMA's table that CMS has currently adopted was to provide a guideline with parameters, but not specific lists of what's included and what's not, which is probably why they took diagnostic endoscopy out. I still feel very comfortable placing diagnostic endoscopy in the moderate risk category.

Standard of care and whether the risks must be documented

[23:48] Scott: Ray, comments?

[23:50] Ray: Yes. Back in the old days, the Coding and Reimbursement Committee of the AUA had this discussion, and it was agreed upon that it should be put in the moderate category.

[24:06] Scott: And if you think about it, whenever you're doing a cystoscopy, there's a reason for doing it, which also has risk, because you're doing it to learn something. So it's not just the risk of the procedure; there is additional risk because there's a reason for doing the cystoscopy.

[24:35] Ray: And there's also a lot of risk in doing the endoscopy. But the real question, I guess, Mark, is if it's accepted by your specialty as standard of care, do you still have to document it for reimbursement purposes?

[24:56] Mark: I would say no, and that's specifically in the guidelines. I'll give you just one segment here that basically said definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified healthcare professional in the same specialty, which is in the AMA CPT guidelines. So again, this really lends credence to the fact that the specialty, urology and the AUA, did look at cystoscopy as moderate risk. That gives credence to this, in addition to the fact that diagnostic endoscopy was in that original risk table. I think we've got multiple places to hang our hat here, and again, that's why I'm still very comfortable leaving cystoscopy in the moderate risk category.

[25:58] Scott: I think that makes a lot of sense and has logic behind it.

Where the risk language belongs in the note

[26:02] Ray: You mentioned putting all that legalese in there for all purposes, but in reality, are you comfortable in just saying the cystoscopy is a moderate risk without adding in the infection and the trauma, et cetera, et cetera?

[26:24] Mark: I am for billing purposes. But again, in the end, your documentation these days has to support shared medical decision making, and ultimately that piece of the risks and benefits of anything you do is part of shared decision making. The patient needs to understand what's happening, and it needs to be clear that you explained it all if it goes into the medical-legal world, and we all know how much fun lawyers have with everything that happens if something goes wrong. So the more you can, the better off you are. That's what the patient's mantra is going to be.

[27:12] Scott: So if you can add the fluff in the template.

[27:16] Mark: Added under shared decision making and the risks and benefits category, not in your assessment and plan.

[27:26] Ray: Good point. We talk about how they split the reimbursement rules and regs, and there's so much more detail. The lawyers have ruined everything we do in modern history with the details they are requiring.

[27:47] Mark: I think that's a different podcast. And unfortunately it's not just the lawyers. Yes, they're a part of it, but it's everybody, because if there weren't a complaint, there wouldn't be a lawyer to jam it. It's top to bottom. We can focus it on the lawyers and their creativity, but everybody's trying to do their job with the parameters they've got. And I have definitely had lawyers that helped me and lawyers that hurt me, so I'm back and forth on those guys and women.

[28:30] Scott: And you can see where this question is coming from, because as the details, or the innuendos in the notes and the parentheses, and so many more little rules are being enforced because they can be, because of AI, because of computer-assisted coding, you can make those rules more enforceable at a more micro level. So that's a great question that was just asked, and it's becoming more and more interpreted to that degree.

[29:14] Ray: So, not to get lost in the discussion, to answer the question: for reimbursement purposes, he doesn't have to explain what the risks are on cystos. It is a moderate risk. But you're talking about adding all of the legalese and all of the stuff to protect you in a template somewhere that goes in your chart.

[29:47] Mark: Correct. Which also can be used to support this. It's a nice little loop that's there. But he's right in asking the question, and to cut down the administrivia, you don't have to put it in both places.

Sponsors and closing thoughts

[30:06] Scott: All right. Let's wrap this episode up here. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or practice management system, you can go to modmed.com/prs for specials for our listening audience. We also want to make you aware that the PRS Coding and Reimbursement Hub is live and getting more and more populated each week. If you want to check out the prostate biopsy section, you can go to prsnetwork.com/urologyhub, and under the category section choose prostate biopsies. All right, let's get some final thoughts. Mark, what are your final thoughts today?

[30:56] Mark: I think the theme of today was interpretation in all of this, and interpretation balanced with intent, I think, is the key that we all need to keep in mind in what we're doing. Unfortunately, as I've watched groups grow larger and insurance companies go more micro on everything, we have to really walk that fine line of making sure that our interpretations balance with the intent and the group think that is out there related to definitions, because we're all capable of reading and twisting things as needed to our own purposes. So remember that as you're going through this. We try to remember that as we go through each one of these things, and it's easy to get lost in the minutia. But try to stay above the fray and stick with that which is generally accepted as we interpret all these rules. And then of course we have to add the caveat, which is that each one of the payers gets some final say in all of this, because of the golden rule: those with the gold make the rules.

[32:22] Scott: Ray, final thoughts.

[32:27] Ray: My final thoughts are that, Mark, that was well said. And just keep in mind, this kind of reminded me that when you're trying to make a decision on what's right and what's wrong, think of what your colleagues would decide, because standard of care is still the basis for a lot of decisions.

[32:53] Scott: Yep. All right. That's all we have for today's episode. Thank you all for listening. Take us out, Ray.

[33:03] Ray: Happy coding.

 PRS Coding and Reimbursement Hub

Access the Hub

Botox LCD Alert

Download the Alert

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

Download Now

PRS Coding Courses

For Urologist

For APPs

For Coders, Billers, and Admins