Pathology/Lab Coding Alert

Method, not number, should lead code choice.

Quarterly updates aren't the only way that Medicare's Correct Coding Initiative (CCI) provides guidance for your lab. If you overlook changes to the National Correct Coding Initiative Policy Manual, you could miss important restrictions -- such as how to report prostate biopsies -- that impact your laboratory compliance.

Background: Each year, CMS updates the Policy Manual, which offers rationales for various CCI edits, as well as establishing compliance and coverage policies you must heed. A Jan. 2012 update provides several changes that you've read about in Pathology/Lab Coding Alert articles such as "83704: Look for NMR Lipoprotein Limits and Opportunities" in Vol. 13 no 3.

Tweak Prostate Saturation Biopsy Rules

Although the latest Policy Manual lists "5" as the strict number cutoff for choosing your prostate saturation biopsy code, the number is not the only thing you need to take into account.

First thing: Before you even consider the new guidance, you need to distinguish between prostate saturation biopsy and other prostate biopsy sampling methods.

Surgeons may perform prostate biopsies using different procedures such as the following:

• 55700 -- Biopsy, prostate; needle or punch, single or multiple, any approach
• 55706 -- Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance.

"The pathologist typically receives about 10 to12 specimens from a traditional needle or punch prostate biopsy procedure, but is likely to see 20 to 40 or more from a prostate saturation biopsy," says R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.

But the number of specimens does not distinguish the two surgical codes -- the surgical procedure does. Similarly, the number of specimens is not the first consideration for choosing the proper pathology exam code -- the surgical procedure is.

Do this: If the pathologist examines prostate biopsies from surgical procedure 55700, you should report the pathologist's work as 88305 (Level IV - Surgical pathology, gross and microscopic examination; prostate, needle biopsy) x the number of specimens received.

If, on the other hand, the pathologist examines prostate biopsies from surgical procedure 55706, CMS has, in the past, required you to choose one of the following codes for Medicare beneficiaries:

• G0416 -- Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling; 1-20 specimens
• G0417 -- ... 21-40 specimens
• G0418 -- ... 41-60 specimens
• G0419 -- ... greater than 60 specimens.

New exception: Here's where the new Policy Manual guidance comes into play. CMS now says that you must use codes G0416-G0419 for the pathology prostate saturation biopsy exam "only if the number of separately identified needle biopsy specimens is five or more. Surgical pathology on four or fewer prostate needle biopsy specimens should be reported with CPT code 88305 with the unit of service corresponding to the number of separately identified biopsy specimens."

Effective rule: Use 88305 x specimen number to report your pathologist's exam of traditional prostate biopsy specimens, as well as saturation biopsy specimens with four or fewer samples.

Caveat: Although the Policy Manual update begins by affirming that G0416-G0419 "describe surgical pathology, including gross and microscopic examination, of prostate needle biopsies from a saturation biopsy sampling procedure," (emphasis added) some experts find the guidance potentially misleading.

"The instruction distinguishing five or more vs. four or fewer samples refers to "prostate needle biopsy specimens," without making the saturation biopsy distinction, so I'm concerned that payers may interpret the Policy Manual to be distinguishing 88305 vs. G0416-G0419 on sample number alone," says William Dettwyler, MTAMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore. Watch future issues of Pathology/Lab Coding Alert for updates on this concern.