55700

Prostate biopsy, with or without guidance

Our Work > Good Faith Estimates > Prostate Biopsy

Recent regulations require hospitals and health plans to publish prices of a subset of services. The hospital rule requires publication of “shoppable services,” those that can be scheduled in advance by a consumer. The Transparency in Coverage rule requires a list of 500 items and services to be published. Prostate biopsy, with our without guidance appears on both lists, and there is a standard service package available for it. The services that make up this package are fairly standard across all prostate biopsy procedures

A prostate biopsy is a procedure to remove samples of suspicious tissue from the prostate. The prostate is a small, walnut-shaped gland in males that produces fluid that nourishes and transports sperm. During a prostate biopsy a needle is used to collect a number of tissue samples from your prostate gland. Your doctor may recommend a prostate biopsy if results from initial tests, such as a prostate-specific antigen (PSA) blood test or digital rectal exam, suggest that you may have prostate cancer. This procedure may be performed with or without imaging guidance; with guidance is presented in this service package as an optional fee

This service package does not include any of the procedures or tests used to determine whether a prostate biopsy is needed, nor does it include any post-procedure follow-up services. Your service utilization may vary from this service package for a number of reasons, including your unique clinical profile and where you receive your services.

This Service Package was generated using outpatient care setting claims. However, this service package may also be performed in the below care settings. Please confirm with your provider in which care setting you will receive services, as this may affect your cost.

  • Inpatient: Discuss with your provider
  • Outpatient facility: 60%
  • Free standing ASC: 40%
  • Office: Discuss with your provider

Item Definitions

Index

Index

this is the fee for the service being defined; note that other codes may be used to define a similar service

Facility Fee

Facility Fee

these fees are most commonly associated with the index event; these may also be
paid to the facility in addition to the index fee

Professional Fee

Professional Fee

these fees are paid to clinicians for the work associated with this service

Optional Fee

Optional Fee

these services are often also billed with the index event, however may vary based on the patient’s individual circumstances

Ancillary Service

Ancillary Service

these are supply codes that identify other services that may be billed with the index event

Proposed Technical Definition

associationbase_codecode_typeestimated_chargeitem_typename
155700CPT3061indexProstate biopsy
1G0416
76872CPT$180facility_feeTransrectal ultrasound
176872CPT296professional_feeTransrectal ultrasound
155700CPT565professional_feeProstate biopsy
0.83272733676942CPT$180optional_fee [facility]Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation
76942CPT$45optional_fee [professional]
88305CPT$1,000facility_feeSurgical Pathology Level 4
0.67288305CPT1200professional_feeSurgical Pathology Level 4
902CPT$430professional_feeAnesthesia
J2704HCPCS$21facility_feePropofol injection
J3010HCPCS$12facility_feeFentanyl citrate injection
0.640037758636Revenue Codefacility_feeDrugs requiring detailed coding
0.607576128402Revenue Codefacility_feeUltrasound imaging
0.554574695360Revenue Codefacility_feeOR services
0.420637695310Revenue Codefacility_feeLaboratory Pathology
0.359367898312Revenue Codeoptional_feeLaboratory Histology
0.309180855250Revenue Codeancillary_servicePharmacy
710Revenue Codeancillary_serviceRecovery Room

Captured Spending (N=40,000)

Decile Base Fee (Facility + Professional) Base Fee + Optional Fees
1 2%
2 0%
3 1%
4 1%
5 1%
6 2%
7 4%
8 8%
9 9%
10 70%

Our Work > Good Faith Estimates > Prostate Biopsy

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