Pathology/Lab Coding Alert

See what CMS’s change from ‘5’ to ‘10’ specimens means for your lab.

If you want to make sure your pathologists’ prostate biopsy exam claims get paid — and you want to get all the pay you deserve — read on for a round-up of current CMS instruction for reporting this services to Medicare.

Units update: In the 2013 National Correct Coding Initiative (CCI) Policy Manual, CMS changed the minimum number of prostate needle biopsies that require you to report a ‘G’ code from five to 10.

Procedure update: The 2013 policy change doesn’t clarify whether you should base the pathology code assignment on the surgical procedure (prostate saturation biopsy versus prostate biopsy) or strictly on the specimen number.

Let our experts show you when and how you should select one of the following codes for your pathologists’ work:

88305 — Level IV - Surgical pathology, gross and microscopic examination. Prostate, needle biopsy

G0416 — Surgical pathology, gross and microscopic examinations for prostate needle saturation biopsy sampling, 10-20 specimens

G0417 — … 21 to 40 specimens

G0418 — … 41 to 60 specimens

G0419 — … greater than 60 specimens.

Cleared Up: Specimen Number for ‘G’ Codes

You’ll find a revised code definition for G0416 in 2013: In prior years, the code identified “1-20 specimens” instead of “10-20 specimens.”

Along with an update to the 2013 CCI Policy Manual that directs you to use G0416-G0419 for “ten or more” separately identified and submitted prostate needle biopsy specimens, the code change clears up a prior contradiction.

Confusion: The 2012 CCI Policy Manual instructed coders to select a code from the range G0416-G0419 for “five or more” prostate specimens, and to use 88305 (times the number of biopsies) for four or fewer specimens. But at the time, the G0416 definition identified “1-20 specimens,” leaving coders with ambiguous instruction for one to four specimens.

Clarification: With the 2013 Policy Manual change and the 2013 code definition change, the contradiction is gone. Both the code definition and the CMS instruction now agree on the cut-off for using the ‘G’ codes: 10 prostate biopsy specimens. Based on the number of cores (10 or more) from a prostate saturation biopsy procedure, you should report a single unit of the appropriate code from the range G0416-G0419.

Impact: “At our institution, the average number of specimens for prostate biopsy is usually four to six,” says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha. With the change, “we’ll rarely see the number of specimens that would indicate the use of the G codes,” she says.

Change Could Cost You $320.48

The change from five to 10 prostate biopsy cores might make more sense for saturation biopsy procedures that often involve many cores — but it could cost you.

For instance: If your pathologist examines five prostate saturation biopsy cores for a Medicare patient this year, you’ll bill 88305x5 and get paid $350.45 (Medicare Physician Fee Schedule global facility total national amount, conversion factor 34.023). Last year, you would have billed the same test for a Medicare patient as G0416, which currently pays $670.93 (Medicare Physician Fee Schedule global facility total national amount, conversion factor 34.023). That’s a pay cut of $320.48.

Small problem: “Given that prostate saturation biopsy procedures typically involve far more than five to 10 cores, the G0416 definition and policy manual change to 10 cores as the cutoff shouldn’t have much practical impact,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark.

If CMS decides to apply the ‘G’ codes only for prostate saturation biopsies (see next section), the change to a 10-core cutoff will haveno impact on billing standard prostate biopsy specimens.

Still Unclear: Surgical Approach Considerations

The number may be clear, but ambiguity remains about whether you should choose the code based strictly on the specimen number, or whether surgical procedure considerations should come into play.

Back story:In 2009, CMS implemented HCPCS Level II codes G0416-G0419 for pathology exam of specimens from a prostate saturation biopsy (55706 — Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance), which often yields 20 or more specimens. The G0416-G0419 definitions linked the codes to prostate saturation biopsy — “Surgical pathology, gross and microscopic examinations for prostate needle saturation biopsy sampling.” That portion of the code definitions remains the same.

For prostate biopsies from other procedures such as 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach), pathologists were to continue billing 88305 for each distinct biopsy core.

The CCI Policy Manual provided instruction in 2012 and 2013 that confirms the code definitions: “Codes G0416-G0419 describe surgical pathology, including gross and microscopic examination, of separately identified and submitted prostate needle biopsy specimens from a saturation biopsy sampling procedure.”

Contradiction: However, the manual goes on to state that, “CMS requires that [G0416-G0419], rather than CPT^® code 88305, be utilized to report surgical pathology on prostate needle biopsy specimens only if the number of separately identified and submitted needle biopsy specimens is ten or more. Surgical pathology on nine or fewer separately identified and submitted prostate needle biopsy specimens should be reported with CPT^®code 88305 with the unit of service corresponding to the number of separately identified and submitted biopsy specimens.”

Resolution in flux: “Although my past communication with the medical director of the NCCI program indicated that you should select 88305 or G0416-G0419 based solely on the number of individually labeled prostate needle core biopsies received for the case, regardless of surgical approach, that might be changing,” says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc. and publisher of the Pathology Service Coding Handbook, in The Villages, Fla.

“Sources such as the American Urological Association and The Dark Report recently have announced their impression that CMS has come full circle and now intends that G0416 is reportable only if 10-20 individual prostate needle biopsies were extracted via formal saturation biopsy sampling surgical procedure (55706),” Padget says.

Do this: “Because CMS’s position cannot be confirmed through an authoritative source at this time, you should consult with your compliance advisor to determine how you should proceed,” Padget advises. Padget is in communication with CMS regarding written confirmation of the G0416 policy; watch Pathology/Lab Coding Alert for up-to-date information.