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    v1.0.30
    OpenPayerBilling CodesExcision Procedures on the EpididymisCPT cpt-54800-epididymal-needle-biopsy-diagnostic
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    CPT 54800: Epididymis Needle Biopsy

    Medicare pays $113 and commercial payers pay $434 on average nationally for this procedure.

    CPT code 54800 describes a needle biopsy of the epididymis, a percutaneous diagnostic procedure performed to obtain tissue from the epididymis for pathologic evaluation; service type: biopsy/diagnostic procedure; typical site of service: outpatient clinic or ambulatory surgery center where urology or surgical providers perform focused scrotal procedures.

    For related coverage guidance, see recent payer policy updates: Removal of Implantable, Outpatient Surgical Procedures - Site of Service, Surgical Procedures.

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    National Reimbursement Benchmarks

    Medicare's mean allowed rate of $113.10 sits well below BUCA's average commercial mean of $434.50, indicating a substantial gap between federal reimbursement and this commercial benchmark for CPT 54800. The commercial mean for BUCA is nearly four times Medicare, reflecting a lender-side commercial market that pays materially higher averages for this code.

    Dispersion measured by the interquartile range (P75 minus P25) varies notably: Blue Cross Blue Shield has the widest IQR at $480.10 ($785.60 - $380.50), followed by BUCA at $252.30 ($547.70 - $262.40) and UnitedHealth Group at $137.40 ($277.90 - $140.50). Aetna and Cigna show tighter spreads of $95.40 ($129.90 - $35.00) and $144.00 ($283.50 - $139.50), respectively, making Aetna the tightest among these payers.

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    National Payer Mean Reimbursement Rates

    State Reimbursement Rates

    State: Alaska1 / 51

    Rate by payer

    Clinical & Coding Specifications

    Clinical Context

    A 34-year-old male presents to a urology clinic with a 4-week history of a painless, palpable mass in the epididymal region of the left scrotum. Physical exam suggests a discrete epididymal nodule separate from the testis. Ultrasound demonstrates a 1.2 cm well-circumscribed hypoechoic lesion of the epididymis without obvious vascular invasion. Conservative management is not definitive and malignancy cannot be excluded. The urologist schedules a percutaneous needle biopsy of the epididymis to obtain tissue for histopathologic diagnosis.

    The clinical workflow includes outpatient consent, pre-procedure ultrasound localization, local anesthesia with or without light sedation, ultrasound-guided needle biopsy of the epididymal lesion, immediate specimen handling for pathology, brief post-procedure observation for bleeding or hematoma, discharge with return precautions, and pathology result review at follow-up. Typical sites of service are outpatient hospital ambulatory surgery centers or office-based procedure rooms staffed by a urology or surgical provider. The procedure supports diagnosis of epididymal cysts, infectious/inflammatory processes, or neoplasm and guides subsequent management such as excision (55040/55041) or aspiration (55100).

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure

    Related Modifiers

    12 rows

    ModifierDescriptionWhen to Use
    26Modifier 26 (Professional Component) identifies and bills only the professional portion of a split service — the physician’s interpretation, report, and medical judgment — when the technical…- Use CPT Modifier -26 when you are billing only the professional component (PC) of a split‑bill eligible service—i.e., you performed the physician interpretation, medical judgment and prepared a…
    50Modifier –50 (Bilateral Procedure) is appended to a CPT code when an identical procedure is performed on paired anatomical structures during the same operative session. The AMA states to add…- Use modifier -50 when the same CPT surgical, diagnostic, or radiology procedure is performed on paired anatomical structures (both sides of the body) during the same operative/session by the same…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    62Modifier 62 indicates that two surgeons function as co‑surgeons, each performing distinct parts of the same primary surgical procedure. It is appended to the primary procedure code (and any…- Use modifier -62 when two surgeons act as co‑surgeons (both primary surgeons) on a single definitive primary procedure, each performing distinct parts of the same surgical procedure (append -62 to…
    76Modifier -76, Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional, is appended when the same provider performs an identical, medically necessary procedure or…- Use modifier -76 when the same physician or other qualified health care professional performs an identical procedure or service a second (or subsequent) time on the same date of service and the…
    78CPT modifier -78 indicates an unplanned, related return to the operating or procedure room by the same provider during the global postoperative period. It is appended when treatment for a…- Use modifier -78 when an unplanned, related complication during the original procedure’s global postoperative period requires the patient to return to a formal operating or procedure room and the…
    80CPT® Modifier 80 (Assistant Surgeon) is appended to a surgical CPT code when a physician (MD or DO) provides full, continuous assistance throughout the operative procedure. It is intended only for…- Use CPT Modifier -80 when a physician (MD or DO) serves as an assistant surgeon and provides full, continuous assistance throughout the entire operative procedure; append -80 to the surgical CPT…
    81Modifier -81 indicates a physician served as a minimal assistant surgeon for part—not all—of an operative procedure. Use when a physician’s assisting role is limited and does not represent full…- Use CPT modifier -81 when a physician acts as a minimum assistant surgeon who assists during only part (a limited portion) of an operative procedure; append -81 to the primary surgical CPT code to…
    82Modifier 82 is appended to a surgical CPT code to indicate that an attending physician acted as an assistant because a qualified resident surgeon was unavailable. In teaching hospitals it documents…- When to use: Append modifier 82 in teaching-hospital settings to indicate a physician served as an assistant surgeon because a qualified resident surgeon was unavailable (includes situations where…

    Showing 1–10 of 12

    Related Provider Taxonomies

    8 rows

    Taxonomy Code
    208800000X
    208600000X
    2088P0231X
    3336C0003X
    282E00000X
    207PT0002X
    225X00000X
    283Q00000X

    Related ICD-10-CM Codes

    20 rows

    ICD-10-CM CodeDescription
    C62.11Malignant neoplasm of descended right testis
    N43.0Encysted hydrocele
    N43.2Other hydrocele
    N43.3Hydrocele, unspecified
    N43.4
    N45.1Epididymitis
    N45.2Orchitis
    N45.3Epididymo-orchitis
    N45.4Abscess of epididymis or testis
    N48.1Balanitis

    Showing 1–10 of 20

    Related Payer Policy Updates

    Specialty: General Surgery1 / 2

    10 rows

    PolicyPayerEffective Date
    Removal of ImplantableBlue Cross Blue Shield - Rhode Island2026-10-01
    Outpatient Surgical Procedures - Site of ServiceUnitedHealthcare2026-09-01
    Surgical ProceduresUnitedHealthcare2026-09-01
    Site of Service Ambulatory Service Center (ASC) Select — Surgical or Diagnostic Procedures in AdultsPremera Bluecross2026-09-01
    Site of Service Ambulatory Surgical Center (ASC) Select — Surgical or Diagnostic Procedures in AdultsPremera Bluecross2026-09-01
    Site of Service Ambulatory Service Center (ASC) SelectPremera Bluecross2026-09-01
    Site of Service Ambulatory Surgical Center (ASC) Select — Site of Service for Ambulatory Surgical Procedures (ASC Select)Premera Bluecross2026-09-01
    Site of Service Ambulatory Service Center (ASC) SelectPremera Bluecross2026-09-01
    Medical Necessity Guidelines Inpatient Surgical CareMass General Brigham Health Plan2026-08-01
    Outpatient Surgical Procedures - Site of Servicesierra health and life2026-08-01

    Related Codes

    CPT-54830-EPIDIDYMIS-LESION-EXCISION

    CPT 54830: Excision of Lesion of Epididymis

    CPT-54840-SPERMATOCELE-EXCISION-EPIDIDYMAL-PARTIAL-EXCISION

    CPT 54840: Spermatocele Excision (Epididymal Cyst)

    CPT-54860-EPIDIDYMECTOMY-UNILATERAL

    CPT 54860: Epididymectomy, Unilateral

    CPT-54861-BILATERAL-EPIDIDYMECTOMY

    CPT 54861: Bilateral Epididymectomy

    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
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    Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

    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.

    55040
    Excision of hydrocele; unilateral
    Surgical excision may be performed if biopsy or imaging suggests definitive pathology requiring removal.
    55041Excision of hydrocele; bilateralBilateral hydrocele excision when pathology or symptoms involve both sides; may follow diagnostic biopsy.
    55100Aspiration of hydrocele, tunica vaginalisMinimally invasive intervention for symptomatic hydrocele; may be performed instead of or prior to definitive excision.
    55250Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s)Related scrotal procedure sometimes performed in the same anatomic region but unrelated diagnostically; included as a commonly associated scrotal surgery code.