Clinical Context
A typical patient is a 65-year-old man with a rising prostate-specific antigen (PSA) level and a suspicious lesion identified on prior multiparametric magnetic resonance imaging (mpMRI). He is referred to an interventional radiologist or urologist for image-guided targeted prostate biopsy. The clinical workflow begins with review of the mpMRI to localize the lesion(s). On the day of the procedure the patient is prepped and positioned inside the MRI or CT scanner. Conscious sedation or monitored anesthesia care is provided as appropriate. Real-time MRI or CT imaging is used to guide a transperineal or transrectal needle trajectory directly into the targeted lesion. Multiple cores are obtained from the targeted area, with additional systematic cores as determined by the clinician. Post-procedure imaging or ultrasound may be used to confirm needle position and assess immediate complications. The patient is observed for bleeding or urinary retention, given post-biopsy instructions including antibiotics and activity restrictions, and scheduled for follow-up to review pathology results and plan definitive management if clinically indicated.
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|
55700 | Biopsy, prostate; needle or punch, single or multiple, any approach | Represents conventional non-image-targeted prostate biopsy often performed as systematic sampling; may be performed in addition to targeted biopsy. |
76872 | Ultrasound, transrectal; prostate, including guidance for needle placement | Often used for transrectal guidance and fusion targeting; may be used before, during, or instead of CT/MRI guidance.
72197 | Magnetic resonance (MR) imaging, pelvic, without contrast material followed by contrast material and further sequences; prostate protocol (e.g., multiparametric MRI) | Pre-procedure multiparametric MRI is commonly used to identify and localize targets for 55714.
77012 | CT guidance for percutaneous needle placement | CT guidance codes apply when CT is used to guide percutaneous needle placement; may be reported for CT-guided prostate biopsy when payer allows.
55706 | Biopsy, prostate, transperineal, single or multiple, with transrectal ultrasound guidance, when performed | Represents transperineal approach with ultrasound guidance; may be an alternative technique performed in the same clinical context.
99152 | Moderate sedation services provided by the same physician performing the diagnostic or therapeutic service, initial 15 minutes | Sedation and anesthesia-related services that may be reported when moderate sedation is provided during the image-guided biopsy.