Pathology/Lab Coding Alert

Get ready for G0416-G0419 with this handy chart Although you-ll see a big pay cut when your pathologists start using the new prostate saturation biopsy codes, you can breathe a sigh of relief: CMS set the payment rate rather than resorting to Medicare contractor pricing. Pathologists and other stakeholders that commented to CMS wanted payment levels based on relative value units (RVUs) that capture the expertise, skill, time, and resources used to diagnose prostate cancer using the saturation biopsy procedure. You can see the new HCPCS Level II codes and the CMS payment rates in the following table. "Don't forget that you should continue to charge 88305 [Level IV -- Surgical pathology, gross and microscopic examination; prostate, needle biopsy] for each individual tissue sample from a prostate biopsy that is not part of a -saturation biopsy- procedure," says Stephen Yurco III, MD, partner and pathologist at Clinical Pathology Associates in Austin, Texas. Understand Payment Formula CMS believes that paying for 88305 to evaluate each of the 20 or even 60 samples from a prostate saturation biopsy "overpays for the pathologist interpretation and report." Instead, CMS priced the new codes as follows: For G0417-G0419, CMS assumes the number of samples is the midpoint of the range (for example, 30 samples for G0417), then bases the price on 88305 for 15 percent of that number, plus half of 88304 for the remaining 85 percent. Because G0416 involves fewer samples, CMS adjusted the formula to start with the 75th percentile HCPCS or CPT Code Description Medicare Payment* G0416 Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 1-20 specimens $634.41 G0417 Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 21-40 specimens $1232.76 G0418  Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 41-60 specimens $2,115.67 G0419  Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, greater than 60 specimens $2511.32 88305  Level IV -- Surgical pathology, gross and microscopic examination; prostate, needle biopsy $103.87 88304 Level V -- Surgical pathology, gross and microscopic examination $61.31  * Payment rate is based on the Medicare Physician Fee Schedule transitional 2009 nonfacility total RVUs x 2009 conversion factor ($36.0666). The values do not reflect geographic cost adjustments.