Pathology/Lab Coding Alert

Palmetto GBA policy sets the tone.

"I'm concerned that payers may interpret the NCCI Policy Manual to be distinguishing CPT 88305 vs. G0416-G0419 on sample number alone," states William Dettwyler, MTAMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore.

That's what we published earlier this year in "Mark 5 Prostate Biopsies as the Magic Cutoff for 88305" (Pathology/Lab Coding Alert Volume 13, Number 5). Now it seems that the concern is becoming reality.

That was Then -- 88305 x 10

In 2009, CMS implemented HCPCS Level II codes 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, as follows:

• 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.

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 (Level IV - Surgical pathology, gross and microscopic examination, Prostate, needle biopsy) for each distinct biopsy core.

Urology standard: The American Urological Association and several international organizations recommend 10-12 core biopsy protocols to improve prostate cancer detection rates and staging/grading of the disease.

"It's not uncommon to examine 10 or more distinct prostate biopsy specimens and bill 88305 x 10 or more," explains R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.

This is Now -- Palmetto GBA Caps 88305 x 4

Palmetto GBA jurisdictions 1 (Calif., Nev., Hawaii) and 11 (N.C., S.C., Va., W Va.) implemented a policy in August that states, "Medicare has limited the number of prostate biopsies that may be reported for CPT® code 88305 to four (4) services. To report five or more prostate biopsies, providers must use G0416 with 1 unit of service."

Effective date: Palmetto states that the policy became effective the first of this year. "Providers who have submitted more than four CPT® codes 88305 services for prostate biopsies for dates of service on and after January 1, 2012 may be at risk for overpayment collection."

Foundation: Palmetto bases the policy on the National Correct Coding Initiative (NCCI) Policy Manual Jan., 2012 update, which affirms that G0416-G0419 are for prostate needle biopsy specimens "from a saturation biopsy sampling procedure." But the manual goes on to state:

"CMS requires that these codes rather than CPT code 88305 be utilized to report surgical pathology on prostate needle biopsy specimens 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."

What it could cost you: Using an example of 12 prostate (not saturation) biopsies, Palmetto's policy would mean that you'd charge 1 unit of G0416 and receive payment of $670.88 (Physician Fee Schedule national payment amount, conversion factor 34.0376). That compares to 88305 x 12 for $1270.32 payment under the old policy.

Watch and Wait

If your lab operates in a Medicare jurisdiction other than Palmetto GBA J1 and J11, what should you do?

You should follow your Medicare contractor's guidance, most of whom have not issued notification of a policy change. You should also scrutinize claims for possible denials.

"Without giving formal notice to providers in their jurisdiction, some contractors may be implementing claim edits 'behind the scenes' to capture and deny units of 88305 in excess of four for prostate biopsies," says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc. and publisher of the Pathology Service Coding Handbook, in The Villages, Fla.

Observe contradiction: The Policy Manual statement is inconsistent (listing saturation biopsy as the method in one G-code reference, but not in another), and G0416 still contains the reference to method-specific prostate needle saturation biopsy sampling and 1-20 specimens (not 5-20), which supports the old policy. Be on the lookout for any CMS clarification on this matter in future issues of Pathology/Lab Coding Alert.