Pathology/Lab Coding Alert

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.

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.

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 cancer diagnosis.

"The pathologist should charge separately for each individual tissue sample taken in a prostate biopsy, using 88305 for each specimen," says Stephen Yurco III, MD, partner and pathologist at Clinical Pathology Associates in Austin, Texas.

Prostate saturation biopsy: "This procedure is for obtaining an exceptionally large number of additional biopsies of the prostate gland in an individual whose previous biopsies have been negative, but there remains a strong clinical suspicion for prostatic carcinoma," explains Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook.

The surgical procedure often involves a transperineal approach with stereotactic image guided sampling using a template or grid to identify the exact location of each biopsy core. The surgeon typically removes 20 to 40 cores -- or more for a larger gland. The prostate saturation biopsy results in a "map" of the prostate gland and the tumor, if present.

When the surgeon sends the pathologist samples from a prostate saturation biopsy, you should select the proper code from the range G0416-G0419 for Medicare beneficiaries, depending on the number of tissue samples.

"To help recognize a prostate saturation biopsy, the pathologist would expect to see evidence that the surgeon -mapped- the location of the biopsy samples," Yurco says.

It's not just the number: You should differentiate the prostate and prostate saturation biopsies based on factors other than just the number of samples. Although you would rarely find a prostate biopsy with greater than 15 samples or a saturation biopsy with fewer than 20, the numbers alone don't define the codes.

TUR is different: Remember that you should use 88305, not the new "G" codes for a TUR prostate specimen. The surgeon acquires a TUR specimen via a "transurethral" surgical approach using a cystoscope with a cutting loop to excise bits of tissue and cauterize the excision site.

Just one specimen: Based on the surgical procedure, you can understand why the prostate TUR specimen is made up of many small pieces of prostate tissue. Even though the pathologist may receive many individual pieces of prostate tissue from a TUR procedure, you should report just one unit of 88305, regardless of the number of blocks.

Still can't decide when to use G0416-G0419 or 88305 for the pathologist's prostate biopsy exam? With a new code in CPT 2009, you can let the surgical procedure be your guide.

Until Jan. 1, surgeons reported prostate needle biopsy with only one code: 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach). Now surgeons will choose between 55700 and new code 55706 (Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance), which replaces Category III code 0137T (Biopsy, prostate, needle, saturation sampling for prostate mapping).

Do this: When your pathologist examines prostate needle biopsies (not TUR) from a 55700 procedure, you should report 88305 for each specimen. When your pathologist examines samples from a 55706 procedure, you should select the proper code from the range G0416-G0419 for Medicare beneficiaries.

"The only way to guarantee that you-re coding the pathology exam correctly may be to know the surgical code," Yurco says.

Look at the following scenario to see how the new "G" codes might affect your bottom line:

Scenario: For a Medicare patient at high risk for prostate cancer despite prior negative prostate biopsies, the surgeon performs a template-guided prostate sampling under radiological direction, removing 20 prostate needle cores. He sends the tissue to the pathologist for interpretation, with each core specifically identified by location on the sampling grid.

The pathologist examines each of the 20 prostate tissue samples and reports his findings to the surgeon, denoting the location of each sample diagnosis on the grid to provide a "map" of the tumor.

New way: Starting Jan. 1, you should report this service as G0416. Medicare will pay $634.41 for the service (see the table on page 110 for pricing information).

Old way: Before HCPCS 2009 was in effect, you would have reported the pathologist's service as 88305 x 20. Under 2008 pricing, Medicare would pay $2,047.00 for the service.

That's why CMS claimed that using 88305 "to bill individually for the evaluation of each biopsy sample would result in overpayment for this service," and introduced the new "G" codes.

Caution: That's also why you need to be sure to distinguish standard prostate needle biopsies and prostate saturation biopsies. If you wrongly code a standard prostate biopsy with 12 cores as G0416 instead of 88305 x 12, you stand to lose $593.79 of your rightful pay ($102.35 x 12" $634.41).

Yes, you can still use 88305: To avoid confusion, CMS clarified that under the Medicare physician fee schedule, "CPT code 88305 will continue to be recognized for those surgical pathology services unrelated to prostate needle saturation biopsy sampling."