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LUGPA Policy Brief:
Prostate Biopsy Reimbursement, Medicare Challenges and Reform Pathways

September 2025

Prostate biopsies are essential for diagnosing prostate cancer, which affects over 299,000 men annually in the U.S. Independent urologists, who deliver the majority of community-based care, depend on fair Medicare reimbursement to sustain access. Yet cuts to the Medicare Physician Fee Schedule (MPFS), administrative hurdles, and site-of-service disparities threaten the viability of independent practices.

This brief reviews reimbursement structures, highlights current challenges, and outlines reforms needed to protect access and preserve independent urology.

CPT 55700 Deletion

  • Status: The AMA CPT Editorial Panel voted in May 2024 to delete CPT 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach), effective January 1, 2026.
  • Replacement: Nine new Category I CPT codes will replace 55700, bundling biopsy with specific imaging guidance (e.g., transrectal ultrasound, MRI).
    • Non-imaging-guided biopsies: Revises CPT 55705 (Biopsy, prostate; incisional, any approach) to specify non-imaging procedures.
    • Imaging-guided biopsies: New codes bundle services with imaging (e.g., CPT 76872, MRI-TRUS fusion).
  • Rationale: Bundling reflects modern practice (e.g., MRI-ultrasound fusion) and reduces billing errors by combining frequently co-reported codes.

HCPCS Code G0416 (Saturation Biopsy)

  • Description: Surgical pathology, gross and microscopic examinations for prostate needle biopsy, any method.
  • Medicare Update (Effective 2015): G0416 is a single, inclusive code for all prostate needle biopsies for Medicare, regardless of core count. References to "12+ specimens" are outdated for Medicare.
  • Other Payers: Private payers may follow CMS or require CPT 88305 based on specimen count. Verify payer-specific rules.
  • Modifiers:
    • -26: Professional component (pathologist’s services).
    • -TC: Technical component (laboratory/equipment costs).
    • -59: Distinct service, only for unrelated procedures on the same date.

Category III Code (0898T)

  • Description: AI-augmented, image-guided biopsy (e.g., MRI-TRUS fusion, Unfold AI).
  • Status: Will remain active in 2026, reimbursement varies by payer, often requiring prior authorization due to emerging technology.

Reimbursement

  • 2025:
    • Conversion Factor: $32.3465.
    • G0416: ~$354.52 (~10.96 RVUs × $32.3465).
    • CPT 55700: ~$240.67 (non-facility), ~$128.49 (facility) at 7.23 RVUs.
  • 2026 (Estimated):
    • Conversion Factors (Proposed, July 2025 MPFS):
      • APM Participants: $33.59 (+3.8% from 2025).
      • Non-APM Participants: $33.42 (+3.3% from 2025).
    • G0416: ~$366–$368 (~10.96 RVUs × $33.42–$33.59).
    • New Codes: ~$240–$260 (non-facility), ~$125–$145 (facility) at ~7.23 RVUs.
  • Calculation: Payment = (Work RVU + Practice Expense RVU + Malpractice RVU) × Conversion Factor.

Documentation

  • G0416: Document all specimens clearly; specify core count if required by non-Medicare payers.
  • New Codes: Detail imaging modality (e.g., ultrasound, MRI) and procedure specifics for medical necessity and billing accuracy.

Payer Notes

  • Medicare follows MPFS; local coverage determinations may apply.
  • Commercial payers vary on G0416 and 0898T, often requiring prior authorization.

Key Challenges for Independent Urologists

  1. Declining Reimbursements
  2. Self-Referral Scrutiny
    • Many urology practices maintain in-house pathology services to streamline care and improve efficiency. However, studies suggesting higher specimen counts in self-referring practices have raised concerns under the Stark Law, potentially discouraging integrated care models and increasing compliance costs.
  3. Site-of-Service Payment Disparities
    • Hospitals receive higher payments under the Outpatient Prospective Payment System (OPPS), with a 2.9% increase projected for 2025, compared to lower MPFS rates for identical services in independent practices. This disparity incentivizes hospital consolidation, shifting patients away from community-based urology practices.
  4. Administrative Burden
    • Increasing requirements for prior authorizations, Merit-based Incentive Payment System (MIPS) reporting, and National Correct Coding Initiative (NCCI) bundling rules elevate administrative costs without corresponding reimbursement increases.
    • Workforce shortages and frequent payer denials further complicate the delivery of biopsy and other urologic care, straining practice resources.
  5. Reduced Patient Access
    • Financial and regulatory pressures contribute to practice closures and mergers, reducing care options, particularly in rural and underserved areas. This disproportionately impacts Medicare beneficiaries, who face growing barriers to accessing urologic care.

Reform Recommendations\

  1. Stabilize Payments
    • Support legislation like H.R. 879, which would reverse the 2025 cut and add inflation-based updates tied to the Medicare Economic Index (MEI).
  2. Advance Site-Neutrality
    • Equalize payments across office and hospital settings to curb consolidation and save Medicare billions.
  3. Promote Alternative Payment Models (APMs)
  4. Reduce Administrative Burdens
    • Streamline prior authorizations and MIPS reporting. Adjust NCCI edits to allow fair billing for imaging guidance and related services.
  5. Protect Integrated Care
    • Clarify rules to allow in-house pathology without undue scrutiny, recognizing the value of coordinated, patient-centered care.

Prostate biopsy reimbursement is crucial to maintaining independent urology practices and ensuring timely, high-quality cancer diagnosis. Current Medicare policies, characterized by ongoing cuts, site-of-service disparities, and regulatory pressures, are accelerating consolidation, increasing costs, and eroding access to care.

LUGPA urges Congress and CMS to implement site-neutral payments, inflation-based updates, reduced administrative burdens, and support for innovative APMs. These reforms are vital to preserve patient access and the future of independent urology.