CCANTER
Networker
I have the following documentation where provider stated it was ultrasound guided with MRI-fusion guidance prostate biopsy. CPT code 55710.
However, I feel like there is no documentation to support the MRI fusion guidance? Or if there is can someone show me what documentation does support that in this procedure note please?
and if this does not support what documentation is necessary to support the MRI fusion guidance?
MRI on January 27, 2025, showed large geographic non-enhancing area in left hemiprostate with no PIRADS 3 or higher lesions. Recent MRI on November 5, 2025, shows post-treatment changes in left prostate without evidence of residual or recurrent disease but reveals concerning new PIRADS 4 lesion in transition zone apex at 10 o'clock measuring 7 mm on the right side. Rising PSA trend and new lesion warrant tissue sampling.
Procedure: Transperineal prostate needle biopsy
Findings:
Preprocedural PSA: 9.6ng/mL (corrected for finasteride use)
Prostate measurements: 5.3 x 4.6 x 5.6cm
Prostate volume: 75cc
PSA density: 0.128ng/cc^2
No hypoechogenic areas suggestive of malignancy were noted on transrectal ultrasound.
No hyperechogenic areas consistent with prostatic calculi or capsular irregularity were observed.
Twelve systematic transperineal biopsies were obtained targeting the paramedian apex and base, posterior apex and base, lateral, and anterior regions of both the right and left sides of the prostate. This distribution ensured thorough sampling of all clinically relevant zones of the gland.
Additional targeted biopsies were taken from the PI-RADS 4 lesion at the 10 o'clock position of the TZ apex.
Description of Procedure:
The risks, benefits, and alternatives of the procedure were reviewed in detail with the patient. Informed consent was obtained.
The patient was placed in the dorsal lithotomy position and the perineum was prepped and draped in the usual sterile fashion. A biplanar transrectal ultrasound probe was inserted into the rectum and oriented to provide both transverse and sagittal images of the prostate. Prostate size, contour, and echotexture were assessed, with findings as noted above.
Local anesthesia was achieved by perineal skin infiltration with 1% lidocaine followed by a bilateral periprostatic nerve block using 10 mL of 0.5% Marcaine under ultrasound guidance. A transperineal stepper unit and grid template were utilized to guide systematic sampling.
Cores were obtained with a spring-loaded 18-gauge biopsy needle via the perineal approach, ensuring accurate sampling from the locations noted above. The needle was withdrawn between each core, and care was taken to avoid overlap of sampling areas. Hemostasis was observed throughout.
The patient tolerated the procedure well and remained hemodynamically stable throughout. He was given postoperative instructions including signs of infection, bleeding, and urinary retention, and advised to maintain hydration. He will be contacted with the biopsy results when pathology becomes available
However, I feel like there is no documentation to support the MRI fusion guidance? Or if there is can someone show me what documentation does support that in this procedure note please?
and if this does not support what documentation is necessary to support the MRI fusion guidance?
MRI on January 27, 2025, showed large geographic non-enhancing area in left hemiprostate with no PIRADS 3 or higher lesions. Recent MRI on November 5, 2025, shows post-treatment changes in left prostate without evidence of residual or recurrent disease but reveals concerning new PIRADS 4 lesion in transition zone apex at 10 o'clock measuring 7 mm on the right side. Rising PSA trend and new lesion warrant tissue sampling.
Procedure: Transperineal prostate needle biopsy
Findings:
Preprocedural PSA: 9.6ng/mL (corrected for finasteride use)
Prostate measurements: 5.3 x 4.6 x 5.6cm
Prostate volume: 75cc
PSA density: 0.128ng/cc^2
No hypoechogenic areas suggestive of malignancy were noted on transrectal ultrasound.
No hyperechogenic areas consistent with prostatic calculi or capsular irregularity were observed.
Twelve systematic transperineal biopsies were obtained targeting the paramedian apex and base, posterior apex and base, lateral, and anterior regions of both the right and left sides of the prostate. This distribution ensured thorough sampling of all clinically relevant zones of the gland.
Additional targeted biopsies were taken from the PI-RADS 4 lesion at the 10 o'clock position of the TZ apex.
Description of Procedure:
The risks, benefits, and alternatives of the procedure were reviewed in detail with the patient. Informed consent was obtained.
The patient was placed in the dorsal lithotomy position and the perineum was prepped and draped in the usual sterile fashion. A biplanar transrectal ultrasound probe was inserted into the rectum and oriented to provide both transverse and sagittal images of the prostate. Prostate size, contour, and echotexture were assessed, with findings as noted above.
Local anesthesia was achieved by perineal skin infiltration with 1% lidocaine followed by a bilateral periprostatic nerve block using 10 mL of 0.5% Marcaine under ultrasound guidance. A transperineal stepper unit and grid template were utilized to guide systematic sampling.
Cores were obtained with a spring-loaded 18-gauge biopsy needle via the perineal approach, ensuring accurate sampling from the locations noted above. The needle was withdrawn between each core, and care was taken to avoid overlap of sampling areas. Hemostasis was observed throughout.
The patient tolerated the procedure well and remained hemodynamically stable throughout. He was given postoperative instructions including signs of infection, bleeding, and urinary retention, and advised to maintain hydration. He will be contacted with the biopsy results when pathology becomes available