Magnetic resonance imaging (MRI)-guided prostate biopsy has gained a lot of attention recently due to its potential to increase accuracy compared with traditional two-dimensional (2D) transrectal ultrasound (TRUS)-guided biopsy or perineal biopsy. Coding for the procedure has been a topic of debate, not only because there are different techniques used for MRI-guided prostate biopsy, but because there are no specific Current Procedural Terminology® (CPT) codes to describe some of the techniques.

Different techniques can be used for MRI-informed biopsies, including direct MRI-guided biopsy (in-bore), cognitive registration, and MRI-TRUS fusion biopsy.  For direct MRI-guided biopsy, the procedure is performed in the MRI gantry itself. For cognitive registration, the provider studies the previously obtained multiparametric MRI with three-dimensional (3D) processing images, and mentally determines the location of lesions concerning for cancer, and subsequently targets these areas during TRUS biopsy. In MRI-TRUS fusion biopsy, the previously obtained MRI images are fused to real-time TRUS images to theoretically allow more specific and precise biopsies; this procedure uses proprietary equipment and can be performed under local or general anesthesia.

The current CPT codes that may be used for these types of procedures include the following:

CPT code 76872: Transrectal ultrasound; this is a diagnostic test for evaluation of the prostate and surrounding structures, looking for abnormalities or suspicious areas worrisome for cancer

CPT code 55700: Biopsy, prostate; needle or punch, single or multiple, any approach

CPT code 76942: Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation

CPT codes 72195-72197: Magnetic resonance (eg, proton) imaging, pelvis (without, with, or without and with contrast)

CPT code 76376: 3D rendering with interpretation and reporting of computed tomography (CT), MRI, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation

CPT code 76377: 3D rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation

CPT code 76498: Unlisted magnetic resonance procedure, (eg, diagnostic, interventional)

When the multiparametric MRI is performed, the MRI itself and the 3D rendering are typically performed by and billed by the radiologist, and therefore should not be billed by the urologist.

For MRI-TRUS fusion biopsy, there are currently no specific CPT codes that describe this ­procedure. In addition, this procedure is ­considered investigaional by many insurance carriers. There are increased costs associated with this procedure, including the cost of the specialized equipment and the additional time needed to build the fusion model, perform virtual biopsies (to limit the ­number of actual biopsies needed), and to ­perform the targeted ­biopsies. Unfortunately, despite the increased costs, the ­current ­applicable codes for the urologist are the same three codes used for standard 2D TRUS-guided biopsy (CPT codes 76872, 76942, and 55700). It is not appropriate for the urologist to bill CPT code 77021 (Magnetic resonance guidance for needle placement [eg, for biopsy, needle aspiration, injection, or placement of localization device], radiologic supervision and interpretation), as this would be the correct code to bill if the patient had been on the MRI gantry.  It is not appropriate to bill CPT codes 76376 or 76377 for the 3D interpretation of the MRI if this has already been billed by the radiologist.  One may try to bill code 76498 (Unlisted magnetic resonance procedure [eg, diagnostic, interventional]) for the additional work of fusing the MRI and the ultrasound, but it is unlikely to be reimbursed. Similarly, if a 3D image from the TRUS is being performed and images captured, one can try to bill for this code (76376 or 76377), but it may be necessary to check with insurance providers to see their coverage policy. Physicians’ offices may choose to have their patients sign an Advanced Beneficiary Notice for procedures that are typically not covered.