Pathology/Lab Coding Alert

Surprise definition change in MPFS could cost your practice plenty.

Out of the blue, the Medicare Physician Fee Schedule (MPFS) final rule changes the way your pathologists must report prostate biopsy examinations — and it’s not pretty.

In fact, you could stand to lose nearly $150 for a standard, 12-specimen prostate biopsy case when billing for Medicare beneficiaries.

Let us help you make the transition by explaining what changed and how you should use the CPT® and HCPCS Level II codes for prostate biopsy exam for Medicare beneficiaries as of Jan. 1, 2014.

Unexpected Code Revision Removes ‘Saturation’

With no prior warning, the MPFS announced the definition change for parent code G0416 (Surgical pathology, gross and microscopic examination for prostate needle biopsies, any method; 10-20 specimens) and subsequent codes G0417-G0419 (for increasing specimen number). This new definition drops the term “prostate needle saturation biopsy sampling” in favor of “prostate needle biopsies, any method.”

Along with specific instruction in the final rule, the definition change makes it plain that you should now use the G codes for all prostate biopsies with 10 or more specimens for Medicare beneficiaries.

Before the change, some Medicare instruction indicated that the G codes were reserved for specimens from prostate saturation biopsy procedures (e.g., 55706 — Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance).

Code differently: That means you should no longer report 88305 (Level IV - Surgical pathology, gross and microscopic examination, Prostate, needle biopsy) times the number of specimens for 10 or more “non-saturation” prostate biopsy specimens for Medicare patients. Instead, select the appropriate code from the range G0416-G0419 based on the number of specimens.

Code the same: For fewer than 10 prostate biopsy specimens from a Medicare beneficiary, “you should continue to report 88305 (Level IV - Surgical pathology, gross and microscopic examination, Prostate, needle biopsy) x the number of specimens,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark.

Pay impact: For global prostate biopsy exam of 12 specimens, the pay difference based on this change in 2014 would be 18.18 RVUs ($ 494.51) for G0416 versus 23.64 RVUs ($ 643.00) for 88305x12 (payment based on CF 27.2006).