Summary & Overview
CPT 55700: Urology Procedure in Outpatient Hospital Setting
CPT code 55700, a urology procedure commonly performed in outpatient hospital settings, is set to be deleted as of December 31, 2025. This change has significant implications for providers, payers, and patients nationwide, as the code has been widely used for prostate-related diagnoses and interventions. The publication examines the clinical context of CPT 55700, its typical use cases, and the impact of its deletion on medical billing and reimbursement practices.
Key payers included in the analysis are Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare. Readers will gain insight into the code's historical utilization, associated diagnoses such as malignant neoplasm of the prostate and benign prostatic hyperplasia, and relevant modifiers like 26, TC, and 59. The article also highlights related CPT codes and physician taxonomies, providing a comprehensive overview of the billing landscape for urology services.
This summary offers benchmarks, policy updates, and clinical context to help stakeholders understand the transition away from CPT 55700 and prepare for changes in coding and reimbursement. The publication is designed for a national audience, focusing on the broader implications of the code's deletion and its role in outpatient urology care.
CPT Code Overview
CPT 55700 was previously used to report a urology procedure performed in an outpatient hospital setting (Place of Service 22). This code is scheduled for deletion effective December 31, 2025. The procedure typically involved services within the urology specialty, reflecting its clinical relevance for outpatient care. Data not available in the input regarding the specific procedure description.
Clinical & Coding Specifications
Clinical Context
A typical patient scenario involves a male patient presenting to the outpatient hospital setting with symptoms such as urinary difficulties, elevated prostate-specific antigen (PSA), or gross hematuria. The patient may have a history or suspicion of prostate cancer, benign prostatic hyperplasia, or other prostate disorders. The clinical workflow includes evaluation by a urology physician, followed by a prostate biopsy or related procedure coded as 55700. The procedure is performed to obtain tissue samples for diagnostic purposes, often in response to abnormal PSA levels or imaging findings. The service is typically rendered by a urology, radiation oncology, or neuroradiology physician, depending on the clinical context.
Coding Specifications
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Modifiers:
- Modifier
26: Used to indicate the professional component of the service, typically when the physician interprets the results but does not own the equipment. - Modifier
TC: Used for the technical component, representing the use of equipment and facilities without physician interpretation. - Modifier
59: Indicates a distinct procedural service, used when multiple procedures are performed and need to be reported separately.
- Modifier
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Provider Taxonomies:
| Taxonomy Code | Specialty |
|---|---|
208800000X | Urology Physician |
2085R0202X | Radiation Oncology Physician |
2085N0700X | Neuroradiology Physician |
These taxonomies represent the specialties typically involved in performing or interpreting the procedure associated with 55700.
Related Diagnoses
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C61- Malignant neoplasm of prostate- Relevant for patients undergoing prostate biopsy to diagnose or confirm prostate cancer.
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N40.1- Benign prostatic hyperplasia with lower urinary tract symptoms- Indicates patients with enlarged prostate causing urinary symptoms, often evaluated with biopsy to rule out malignancy.
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R97.20- Elevated prostate specific antigen [PSA]- Used when patients have abnormal PSA levels, prompting further investigation with prostate biopsy.
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N42.9- Disorder of prostate, unspecified- Applies to patients with non-specific prostate disorders requiring diagnostic clarification.
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R31.0- Gross hematuria- Represents visible blood in urine, which may necessitate prostate evaluation and biopsy to determine the underlying cause.
Related CPT Codes
55725- Incision Procedures on the Prostate
55725 is related to 55700 as both involve surgical intervention on the prostate. While 55700 is used for biopsy procedures, 55725 covers incision procedures, which may be performed for therapeutic or diagnostic reasons. These codes may be used together in cases where both biopsy and incision are required, or as alternatives depending on the clinical indication.
National Reimbursement Benchmarks
Nationally, the mean rate for CPT code 55700 among BUCA (average commercial) payers is $323.35, which is higher than the Blue Cross Blue Shield mean rate of $254.81 and lower than Cigna's mean rate of $432.91. Aetna and UnitedHealth Group also report mean rates above $350, with Aetna at $362.03 and UnitedHealth Group at $355.70.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies significantly across payers. Blue Cross Blue Shield shows the tightest range at $120.00, while Cigna exhibits the widest spread at $226.17. BUCA's range is $168.49, Aetna's is $164.50, and UnitedHealth Group's is $198.00. This indicates that Cigna's rates are the most variable, while Blue Cross Blue Shield's are the most consistent nationally.
The table and chart below present a detailed breakdown of national mean rates and percentile values for each payer.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.