How To Use CPT Code 54800

CPT 54800 describes the procedure of biopsy of the epididymis 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 54800?

CPT 54800 is used to describe the biopsy of the epididymis using a needle. This procedure is performed by a healthcare provider to obtain a sample of epididymal tissues for the diagnosis of various medical conditions affecting the epididymis.

2. Official Description

The official description of CPT code 54800 is the “Biopsy of epididymis, needle.” This code specifically refers to the excision of a sample of diseased tissues from the epididymis using a needle. It is important to note any additional notes or guidelines provided for this code.

3. Procedure

1. The healthcare provider prepares the patient for the procedure, ensuring appropriate anesthesia and sterilization.
2. The provider stretches the scrotal skin to expose the epididymis, which is located behind the testis.
3. A needle is inserted into the epididymis at the targeted location to obtain a tissue sample.
4. The provider carefully withdraws the needle, ensuring minimal discomfort to the patient.
5. If necessary, the provider sutures the needle wound in the scrotum to promote healing.

4. Qualifying circumstances

CPT 54800 is performed when there is a need to diagnose various medical conditions affecting the epididymis. The procedure is typically indicated when other diagnostic methods, such as imaging or laboratory tests, are inconclusive or insufficient. The healthcare provider must determine the medical necessity of the biopsy based on the patient’s symptoms, medical history, and clinical findings.

5. When to use CPT code 54800

CPT code 54800 should be used when a healthcare provider performs a biopsy of the epididymis using a needle. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If the biopsy is performed using a different method or for a different anatomical site, a different CPT code should be used.

6. Documentation requirements

To support a claim for CPT 54800, the healthcare provider must document the following information:

• Indication for the biopsy and the medical necessity
• Details of the procedure, including the use of anesthesia and any complications
• Location of the biopsy site
• Size and nature of the tissue sample obtained
• Any additional procedures performed during the same session
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 54800, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately report the procedure and any associated services or supplies. Review the documentation requirements and ensure that all necessary information is included in the claim. Be aware of any specific guidelines or modifiers that may apply to the billing of CPT 54800.

8. Historical information

CPT 54800 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 performs a needle biopsy of the epididymis to diagnose a suspected tumor.
2. A patient presents with chronic pain in the scrotum, and a healthcare provider performs a biopsy of the epididymis to investigate the underlying cause.
3. During a routine physical examination, a healthcare provider detects an abnormality in the epididymis and performs a biopsy for further evaluation.
4. A patient with a history of infertility undergoes a biopsy of the epididymis to assess the presence of any obstructive factors.
5. A healthcare provider performs a needle biopsy of the epididymis to rule out infection in a patient with persistent symptoms.
6. A patient with a known epididymal cyst undergoes a biopsy to confirm the diagnosis and determine the appropriate treatment.
7. A healthcare provider performs a needle biopsy of the epididymis to investigate the cause of recurrent epididymitis in a patient.
8. A patient with a suspected epididymal abscess undergoes a biopsy to guide the appropriate treatment approach.
9. A healthcare provider performs a biopsy of the epididymis during a surgical procedure for another condition to assess any concurrent abnormalities.
10. A patient with a history of testicular cancer undergoes a biopsy of the epididymis to monitor for any potential recurrence or metastasis.