HCPCS 2009 Avoid Overbilling:
Use New Codes for Prostate Saturation
Published on Wed Jan 23, 2008
Keep using 88305 for standard prostate biopsy or lose pay. You won't be getting $3,000 to $6,000 anymore for the pathology exam of "prostate saturation biopsy" samples for Medicare patients. Instead, you can expect $634 to $2,511, depending on the number of biopsy specimens. That's because CMS implements four new "G" codes for prostate saturation biopsy starting Jan. 1. The codes are G0416-G0419 (Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling -) for 1-20, 21-40, 41-60, and greater than 60 biopsy specimens, respectively. See "Untangle -G- Code Pricing That Affects Your Bottom Line" on page 110 for the full list of codes and pricing for Medicare prostate biopsy procedures. Know the Codes for -Saturation- Samples Before introducing G0416-G0419 for prostate saturation biopsies, coders reported the service just like any other prostate needle biopsy -- by using 88305 (Level IV -- Surgical pathology, gross and microscopic examination; prostate, needle biopsy) for each specimen. That's why payment for a prostate saturation biopsy pathology exam was so high -- you-d charge 20 to 60 biopsies at $103.87 per 88305 (see table on page 110 for payment calculation). That could add up to over $6,000 to examine specimens from a single prostate saturation biopsy. Watch for TUR: The new "G" codes shouldn't impact your coding for all prostate biopsy specimens. That's because needle biopsy isn't the only prostate specimen you report with 88305. You should also use 88305 to report a transurethral resection of prostate (TUR or TURP). Although this is a partial resection specimen, you should not use 88307 (Level V -- Surgical pathology, gross and microscopic examination; prostate, except radical resection), because 88305 (- prostate, TUR) is the most specific code. "You should report 88305 even though pathologists often find the TURP specimen to be more work than the tissue exam from an open partial prostatectomy," says R.M. Stainton Jr., MD, president of Doctors- Anatomic Pathology Services in Jonesboro, Ark. Distinguish Prostate Biopsies, Avoid 2009 Denials Given the huge potential pay variance, you need to be sure that you know the difference between prostate saturation biopsy and more standard prostate biopsy procedures. "Pathologists would like clear direction about when they should use the new -G- codes and when they should continue to report multiple units of 88305," says Ernest J. Conforti, M.S., SCT(ASCP)MT, director, patient financial services for North Shore-Long Island Jewish Health System headquartered in Great Neck, N.Y. Study the following information to pick the right code. Prostate biopsy: A prostate biopsy often involves a transrectal ultrasound (TRUS) guided procedure in which the surgeon samples about 10 to 12 cores from the gland in a systematic pattern. Many clinicians considered this procedure the "gold standard" for prostate [...]
