How To Use CPT Code 54500

CPT 54500 describes the procedure for biopsy of the testis using a needle. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 54500?

CPT 54500 involves the removal of a tissue sample from one or both testicles using a needle. This procedure is performed to examine the tissue sample under a microscope for further evaluation.

2. Official Description

The official description of CPT code 54500 is: ‘Biopsy of testis, needle (separate procedure).’ This code is used when a tissue sample is obtained from the testis using a needle, without requiring an incision.

3. Procedure

1. The provider cleans the skin over the testicle and administers local anesthetic if necessary to numb the area.
2. A needle is inserted to obtain a small piece of the testicle tissue.
3. If the biopsy is performed to evaluate the absence of living sperm in semen, the sample is placed in Bouin’s fluid, a preserving solution, and sent to the laboratory for further analysis.

4. Qualifying circumstances

CPT 54500 is performed on patients who require a biopsy of the testis for diagnostic purposes. It is typically used to evaluate infertility or other conditions related to the testicles. The procedure can be performed by a qualified healthcare professional.

5. When to use CPT code 54500

CPT code 54500 should be used when a biopsy of the testis is performed using a needle as a separate procedure. It should not be reported if performed along with a related procedure in the same anatomic area or through the same incision or surgical approach. If the procedure is performed with an unrelated procedure, modifier 59, Distinct procedural service, should be appended to the code.

6. Documentation requirements

To support a claim for CPT 54500, the healthcare professional must document the following information:

• Reason for the biopsy and the need for further evaluation
• Details of the procedure, including the use of local anesthetic and the type of needle used
• Date and time of the procedure
• Any complications or adverse events that occurred during or after the procedure
• Signature of the healthcare professional performing the biopsy

7. Billing guidelines

When billing for CPT 54500, ensure that the procedure is performed as a separate procedure and not in conjunction with a related procedure. If the procedure is performed on both testes, modifier 50 should be appended to the code. If an open incision is made instead of using a needle, CPT code 54505 should be reported instead.

8. Historical information

CPT 54500 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A urologist performing a biopsy of the testis using a needle to evaluate infertility in a male patient.
2. A reproductive endocrinologist obtaining a tissue sample from the testis of a patient with suspected testicular cancer.
3. A pathologist performing a biopsy of the testis to examine the tissue for abnormalities.
4. A fertility specialist using a needle to obtain a tissue sample from the testis for further evaluation of sperm quality.
5. An andrologist performing a biopsy of the testis to investigate the cause of testicular pain in a patient.
6. A urologic surgeon obtaining a tissue sample from the testis to diagnose a suspected testicular tumor.
7. A radiologist performing a guided biopsy of the testis using imaging techniques to target the specific area of concern.
8. A pediatric urologist performing a biopsy of the testis in a young patient with undescended testicles.
9. An oncologist obtaining a tissue sample from the testis to determine the stage and type of testicular cancer.
10. A reproductive medicine specialist performing a biopsy of the testis to assess the presence of sperm for fertility treatment.