2025 CPT code 54500
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Male Genital System Surgery Feed
Needle biopsy of the testis (separate procedure).
Modifiers 50 (bilateral procedure) and 59 (distinct procedural service) are commonly used with 54500.Modifier 50 should be used if both testicles are biopsied; Modifier 59 should be used if the biopsy is performed in conjunction with another unrelated procedure.
Medical necessity for a testicular biopsy is established when there is a clinical indication such as a palpable mass, scrotal pain/swelling, infertility evaluation, or suspicion of malignancy. The physician should document the clinical findings and reasoning for the procedure.
The physician cleans the scrotal skin, administers local anesthetic (if needed), inserts a needle to obtain a tissue sample from the testicle(s), and prepares the sample for laboratory analysis (if indicated). The pathologist then interprets the results of the laboratory analysis of the tissue sample.
In simple words: The doctor takes a small tissue sample from one or both testicles using a needle.This sample is then sent to a lab for examination under a microscope. If the test is to check for infertility, a special fluid is used to preserve the sample before it is sent to the lab. This infertility test is billed separately.
This CPT code, 54500, represents a needle biopsy of one or both testicles.The procedure involves cleaning the scrotal skin, administering local anesthetic as needed, and inserting a needle to obtain a tissue sample.If the biopsy is for infertility evaluation (absence of living sperm), the sample is placed in Bouin's solution for preservation and sent to the laboratory.This infertility testing is a separate procedure and billed separately.The code should not be reported if performed with a related procedure in the same anatomic area or through the same approach. Modifier 59 is appended if performed with an unrelated procedure. Modifier 50 is added if both testicles are biopsied.Open testicle biopsy is coded differently (54505).
Example 1: A 35-year-old male presents with a palpable testicular mass.A needle biopsy of the right testicle is performed under local anesthesia to evaluate for malignancy., A 40-year-old male is undergoing infertility workup. A needle biopsy of both testicles is performed to assess sperm production and morphology., A 28-year-old male presents with scrotal pain and swelling. A needle biopsy is performed to evaluate for inflammation or infection.
* Operative report detailing the procedure, including the number of testicles biopsied, location of the sample(s), and the technique used.* Pathology report with microscopic description of the tissue sample and diagnosis.* Consent form for the procedure.* Medical records documenting the indication for biopsy and relevant patient history.
** Always ensure proper documentation and adherence to payer-specific guidelines.For specific payment rates and relative value units, refer to your local payer's fee schedule and relevant coding resources.