Pathology/Lab Coding Alert

Question: Why is there such a huge reimbursement difference for prostate biopsy for Medicare versus non-Medicare patients?

Louisiana Subscriber

Answer: When you bill Medicare for prostate biopsy, you must report a single unit of G0416 (Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method), no matter how many needle specimens the case involves. For non-Medicare payers, you’ll bill one unit of 88305 (Level IV - Surgical pathology, gross and microscopic examination … Prostate, needle biopsy…) for each prostate needle biopsy, with cases often involving multiple specimens.

Let’s say your pathologist examines nine needle biopsies for a prostate case. Code G0416 pays $354.13, regardless of the number of needle cores, while 88305 pays $71.52, leading to total pay of $643.50 (national global non-facility amount, conversion factor $34.89).

Recall: Medicare has gone through multiple rules and codes for how you should bill prostate biopsies, with some iterations specifying the number of needle cores or the sampling method. Even after settling on the current code definition, Medicare pay for G0416 has decreased every year from $649 in 2015, to $534 in 2016, to $491 in 2017, to $435 in 2018, to $386 in 2019, to $348 in 2020, and finally to $354 this year (national global fee, conversion factor $34.89).