Pathology/Lab Coding Alert

Question: If our pathologist receives needle core prostate biopsy specimens in two containers, one labeled right and the other labeled left, with four distinct cores in each container, how should we code this?

Louisiana Subscriber

Answer: Pathologists often examine multiple needle core prostate biopsies, and you can report each distinct examination as one unit of 88305 (Level IV -- Surgical pathology, gross and microscopic examination,prostate, needle biopsy).

Stipulation: The key to answering your question is understanding what constitutes a distinct specimen that warrants an individual examination.

Because the physician separately identifies only two specimens in your example -- left and right -- you should code only two units of 88305. Thats the case, despite each container holding four separate cores.

Although prostate biopsies often involve about 12 separate needle cores, the diagnostic value of multiple specimens involves a systematic sampling that identifies the location of each core. By lumping multiple cores in a single container, the surgeon makes it impossible for the pathologist to provide individual diagnostic information on each core relative to its location in the prostate gland.

Charge one unit of 88305 for each prostate needle biopsy that the surgeon individually identifies and the pathologist individually diagnoses. If you receive two or more biopsies in one vial with no distinction, you can only report one unit of 88305 for that vial.

Red flag: If the pathologist receives multiple cores from a prostate saturation biopsy (surgical code 55706,Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance), you should report the pathology examination for a Medicare patient using the appropriate HCPCS Level II code instead of using 88305:

" 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.