Pathology/Lab Coding Alert

G0416 alone could hurt your bottom line.

CMS thinks your pathologist should get $227 less for a “standard” prostate biopsy case than what most other insurers pay. And if the patient requires more biopsies than a standard case, don’t expect additional pay.

That’s according to the recently-published Medicare Physician Fee Schedule. Let us help you unravel how you should code for prostate biopsies beginning Jan. 1, 2015, how we got here, and what you can expect CMS to do about future reimbursement for those services. 

Use One Code, One Unit

CMS has “simplified” your prostate biopsy coding by giving you just one code choice for Medicare beneficiaries in 2015: revised code G0416 (Surgical pathology, gross and microscopic examination for prostate needle biopsies, any method, 1 or more specimens.). You can see how this varies from the 2014 definition for G0416: Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method, 10-20 specimens.

Impact: If a surgeon submits one prostate needle biopsy or 50 from a Medicare patient in 2015, you’ll use one unit of G0416 to describe your pathologist’s tissue exam. You can no longer use different codes and expect more or less pay based on the number of biopsies submitted.

“That’s a big change from 2014, when the number of specimens impacted your code choice and your pay,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark.

Other payers: For the same scenario, most other payers currently pay for one unit of 88305 (Level IV - Surgical pathology, gross and microscopic examination..., Prostate, needle biopsy) for each separately-identified prostate needle biopsy in a case. 

Count the cost: CMS states in the final rule that, “Based on our review of medical literature and examination of Medicare claims data …, we believe that the typical number of specimens evaluated for prostate biopsies is between 10 and 12.” Looking at the global national payment amount effective Jan. 1 listed in the final rule, you can expect to get paid $649 for a 12-specimen prostate biopsy case using G0416, versus $876 for the same case if you could report it with 12 units of 88305.

You can expect to lose even more pay if your pathologist — with no choice in the matter — examines a case with a larger number of biopsy specimens. As commentators stated in response to the CMS proposed rule, “The decision to furnish more extensive pathological analysis is not at the discretion of the pathologist, and the pathologist should not be penalized when he or she receives more cores to analyze.”

Avoid Old Rules and Deleted Codes

You had to turn to other codes in 2014 if the case involved fewer than 10 or more than 20 specimens, because the G0416 definition specified 10 to 20 prostate needle biopsy specimens. Medicare instructed you to use 88305 for each prostate biopsy specimen if the case included nine or fewer specimens, and to choose one code from a group of other G codes if the case involved more than 20 prostate needle biopsies. 

Forget 88305: “CMS believes that prostate needle biopsy examinations require significantly less resources ‘as regards the number of blocks used to process the specimen and thus the amount of work involved’ than the typical 88305-level specimen,” explains Dennis Padget, MBA, CPA, FHFMA, The Villages, Fla., Senior Editor in Chief, Pathology Service Coding Handbook, for American Pathology Foundation. “Furthermore, [CMS] asserts that to allow ‘CPT® code 88305 to be reported in multiple units for prostate biopsies would account for significantly more resources than is appropriate,’” Padget says.

Drop G0417-G0419: For 2015, CMS deletes the following G codes, so you need to make sure you don’t use them for prostate biopsy cases on or after Jan. 1:

• G0417 — Surgical pathology, gross and microscopic examination for prostate needle biopsies, any method; 21–40 specimens
  
• G0418 — … 41–60 specimens
  
• G0419 — … greater than 60 specimens.
  

Recall: Prior to 2014, CMS limited the use of G0416-G0419 to prostate needle saturation biopsy sampling. For standard prostate needle core biopsies that didn’t involve the mapping function of prostate saturation biopsies, you were to use one unit of 88305 for each specimen. CMS changed the G codes to refer to biopsies by “any method” in 2014.

Focus: Your two choices for reporting prostate needle core biopsies in 2015 are as follows:

• One unit of G0416 for any number of prostate needle core specimens for Medicare beneficiaries (consult your Tricare and Medicaid agencies to see if they also require G0416)
• One unit of 88305 for each prostate needle core specimen for non-Medicare payers, unless otherwise directed by your payer.   

Watch for ‘Misvalued’ Code Payment Change

The change in coding for prostate needle biopsies for Medicare may be over, but the change in your pay might not be. Now that you’re limited to using only G0416 for Medicare beneficiaries, you need to be on the lookout for a possible upcoming reimbursement revision. 

“Code G0416 is being added to CMS’s potentially misvalued code list for relative value review and possible adjustment in the near future,” Padget explains. “The physician professional component allowance for G0416 is only 40 percent of that for 12 units of 88305, so I can’t see how CMS could believe that component as ‘overvalued.’ On the other hand, I, too, would have to conclude that the TC of G0416 is overvalued, considering that it will pay 14 percent more than 12 units of 88305 starting Jan. 1, 2015,” he says.

Re-evaluating payment for G0416 should close the loop on Medicare’s overhaul of coding and reimbursement for prostate needle biopsy cases. You can expect this process to help CMS achieve their stated goal to “simplify the coding and mitigate overutilization incentives” for these services.