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Key points to verify in the documentation: The number of distinct lesions biopsied Whether biopsies were performed on additional lesions requiring add-on code 55715 The approach used (transperineal or transrectal) The type of imaging guidance documented, understanding that imaging is bundled into the new codes If no specific lesion is biopsied, check documentation to see if template saturation biopsy was done If the operative report does not clearly identify the approach, the technique and the number of lesions targeted (if applies), a query should be considered to support accurate CPT code assignment under the new guidelines
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