2025 CPT code 54505
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Male Genital System Surgery Feed
Incisional biopsy of the testis. This is a separate procedure.
Modifiers 50 (bilateral procedure), 59 (distinct procedural service), and laterality modifiers (LT, RT) can be applied when appropriate.
Medical necessity for a testicular biopsy is established by the presence of a clinical condition requiring tissue diagnosis, such as a suspicious testicular mass, infertility, or other relevant symptoms.
The physician prepares the skin over the testes with antiseptic.Under local anesthesia, a small incision is made to obtain the tissue sample. The sample is then sent to a laboratory for analysis.
In simple words: The doctor takes a small tissue sample from one or both testicles through a small cut in the scrotum. This sample is then looked at under a microscope.
The provider performs an incisional biopsy of one or both testicles. The procedure involves making an open incision in the scrotum to remove a tissue sample, which is then sent for microscopic examination.This code should not be reported when the biopsy is performed through the same incision as another related procedure in the same anatomical area.
Example 1: A patient presents with a palpable testicular mass. An incisional biopsy (54505) is performed to determine the nature of the mass., A patient has infertility issues.A testicular biopsy (54505) is performed to assess sperm production., A patient undergoes an orchiectomy (removal of the testicle) for testicular cancer. At the same time as the orchiectomy during the same surgical session, a separate incisional biopsy (54505) is performed on the contralateral testicle to evaluate for possible spread of the cancer.Modifier 59 should be appended to 54505 to indicate it was a distinct procedure.
Documentation should include the operative report detailing the incisional biopsy procedure, the location and size of the incision, the method of obtaining the tissue sample, and any complications encountered. The reason for the biopsy, such as a palpable mass or infertility, should also be documented. Pathology report should be included.
** It's important to distinguish an incisional biopsy (54505) from a needle biopsy (54500) as they have different codes.
- Specialties:Urology, Oncology, Reproductive Endocrinology
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient, Office