Pathology/Lab Coding Alert

Question: I was told that we can’t bill a pinworm exam with a prostate saturation biopsy. Is that true, and if so, why?

California Subscriber

Answer: You are correct that you should not bill a pinworm exam (87172, Pinworm exam [e.g., cellophane tape prep]) with any of the following codes for a Medicare beneficiary as of Jan. 1:

• G0416 -- Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 1-20 specimens

• G0417 -- … 21-40 specimens

• G0418 -- … 41-60 specimens

• G0419 -- … greater than 60 specimens.

Here’s why: CCI version 16.0 created four edit pairs that bundle the pinworm exam with each of the prostate saturation biopsy codes. There is no apparent explanation for these edit pairs. The procedures do not share methodology or specimen type and do not provide similar Pathology/Lab Coding Alert/2010, Vol. 11, No. 1. diagnostic information. You can override the edit pairs with a modifier, if appropriate.

Possible reasoning: CCI may have intended to bundle G0416-G0419 with 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]) instead of 87172.

Recent CCI direction in the updated policy manual (version 15.3) restricts the use of 88172 and no longer allows billing the code “per pass.” Since the prostate saturation biopsy codes also involve needle sampling, it is possible that CCI intended to bundle these “needle” codes to avoid reporting both codes for a single service.