Pathology/Lab Coding Alert

88344 is still ‘per specimen.’

You have only one code choice for Medicare beneficiary prostate biopsy exams, no matter how many cores your pathologist examines. But don’t let that limitation cost you pay for ancillary services such as PIN-4 stains.

Read on to get the low-down on billing prostate biopsy cases to Medicare payers.

Many Cores, One Code

After several iterations and pay changes, Medicare has settled on G0416 (Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method) as the one-size-fits-all code for your pathologists’ prostate-biopsy case exams.

Backstory: Prior to settling on the current G0416 definition, Medicare went through multiple rules and codes for how you should bill those services. Many of the past policies involved G-codes that specified the number of cores or the sampling method, such as prostate saturation biopsy. For some cases, Medicare aligned with the non-Medicare model – reporting one unit of 88305 (Level IV - Surgical pathology, gross and microscopic examination … Prostate, needle biopsy …) for each core in a prostate biopsy case, which might include from 10 to 20 or more individual specimens.

Price implications: Pricing for the G0416 service on the Medicare Physician Fee Schedule (MPFS) has also varied dramatically since 2015, when CMS first required the single G0416 code for all prostate biopsies. Currently, Medicare pays $386.34 for G0416 (2019 MPFS facility or non-facility amount, conversion factor 36.0391).

That amount has decreased every year, partly because CMS revised the average number of specimens expected per prostate biopsy case from 20, to 8 to 10. Along with other factors, the resulting G0416 payment has declined from $649 in 2015, to $534 in 2016, to $491 in 2017, to $435 in 2018, and finally to $386 in 2019 (national global fee).

Currently, for a non-Medicare prostate biopsy exam involving 10 needle-core specimens, your pathologist’s pay might be closer to $702.80 (based on 88305 pay of $70.28 on the 2019 MPFS facility or non-facility amount, conversion factor 36.0391).

“Examining 10 or more needle core specimens in a single prostate biopsy cases would not be unusual,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark.

Check Out Prostate Bx Case

Because Medicare requires just one code for a pathology prostate biopsy case exam, regardless of the number of specimens, some practices have wondered if that means they must also bundle ancillary services for these cases.

Case: The pathologist received prostate biopsy specimens A-L, which are 12 separately submitted biopsies from a single surgical encounter with a Medicare patient. In addition to the pathology exam of all specimens, The pathologist performed an immunohistochemistry (IHC) prostate triple stain (PIN-4) on specimens A, B, and E.

The PIN-4 is a multiplex stain (sometimes called a cocktail), meaning that the lab analyst applies multiple antibodies mixed in a single “stain.” The pathologist can distinctly visualize and interpret each antibody to provide distinct diagnostic information.

For instance: A PIN-4 may contain the following three antibody markers: p504S (cytoplasm red) to identify adenocarcinoma or atypical adenomatous hyperplasia, plus basal cell markers HMWCK (cytoplasm brown) and p63 (nuclei brown) for benign or prostatic intraepithelial neoplasia (PIN) specimens.

The pathologist identifies p504S, HMWCK, and p63 positive or negative for each of the three specimens A, B, and E and issues a report on the findings.

Pinpoint Unit of Service to Code the Case

Because this case is for a Medicare beneficiary, the pathologist must report G0416 for the biopsy examination of specimens A-L. You should not report 88305 x 12 as you could for many other payers.

Although CMS has acknowledged that a typical prostate biopsy case includes multiple specimens, the agency requires just one unit of G0416 to describe the entire pathology-exam service. That doesn’t mean you have to bundle all other specimen-based procedures for multiple prostate biopsy specimens into a single code.

Don’t bundle stains: The code for a multiplex IHC stain is 88344 (Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure). You should bill three units of 88344, because the pathologist examines and reports on the IHC multiplex stain on three distinct prostate biopsy specimens A, B, and E.

“Note that the code definition states, ‘per specimen,’ so you should bill one unit of 88344 for each PIN-4 stain on each separate prostate biopsy specimen,” says Peggy Slagle, CPC, coding and compliance manager for Regional Pathology Services at the University of Nebraska Medical Center in Omaha.

Avoid: Although the pathologist identifies three distinct stains on the slide (p504S, HMWCK, and p63), you should not bill three units of 88344 for a single PIN-4 specimen stain.

“The 88344 code already accounts for multiple, separately interpreted antibody stains on a single slide,” Slagle says.

Beware CCI Edit Limits

Even though CMS doesn’t prohibit multiple units of 88344 with G0416 cases, the agency does provide some limitations for billing multiple units of multiplex IHC stains.

The Correct Coding Initiative (CCI) Medically Unlikely Edits (MUE) table limits the number of units of a specific code that you can bill for a single case.

Further, the MUE table lists an MUE Adjudication Indicator (MAI) for each code, which provides direction for whether the limit is a claim-line or date restriction, and whether you can override the limit.

88344 MUE: In July 2018, CMS changed the 88344 MUE limit from one unit to six units, but simultaneously changed the MAI for the code from MAI-1 to MAI-3.

These changes impact how you should submit claims with multiple units of 88344, and how Medicare will cover multiple units.

What it means: MAI-1 is a claim-line edit, meaning that you can report just one unit of the code on a claim line. If you have multiple units, you should report each code on a separate claim line using an appropriate modifier such as 59 (Distinct procedural service). CMS provides no restriction on how many separate lines you can list for a given code with MAI-1.

But 88344 is now an MAI-3 code, which is a clinical-benchmark date-of-service edit. That means Medicare abides by clinical standards limiting the number of units of 88344 to six multiplex stains per day. You don’t have to report the codes on separate claim lines with a modifier, but you can expect Medicare to initially deny claims with more than six units of 88344 as probably not medically necessary based on the clinical benchmark. You can appeal these cases, and Medicare might pay for more units than the MUE date of service limit with appropriate medical-necessity documentation.