Wiki coding G0416 on prostate saturation biopsies

[ktr]

I am so confused. We are receiving 12 biopsies per case and I do not know if all 12 are coded with just one G0416 code or G0416 x 12- per container- as I would use 88305.
With the January change in this code from 1-20 bx to 10-20 bx, does that mean the first 9 are 88305?
thank you all for your help
ktr

 

[BlakeCarswell82]

For 9 or less, 88305 x 9
For 10-20, G0416 x 1

 

[ktr]

Thank you! That makes the most sense. Now to submit the pre-bill for the G code.
ktr

 

[renesmartpro]

For 9 or less, 88305 x 9
For 10-20, G0416 x 1

Are all insurance companies following the new Medicare/Medicaid guideline for the G0416 for 10-20? Just curious if anyone has seen some payout from other carriers.

 

[BlakeCarswell82]

I am unsure about HMOs, but commercial accounts still have not weighed in on this. We are still billing 88305 and charging per antibody on the 88342. Commercial payers seem to be waiting for CMS to clarify what is happening with these codes.

The G0416 code is highly controversial. The Medicare website says to use the G0416 “regardless of biopsy approach (e.g. saturation or sextant or fiveregion).” However the HCPCS coding manual specifies, “prostate needle saturation biopsy sampling.” To this date, CMS has not clarified this issue in writing.