Update on Prostate HCPCS Codes (G-0416-G-0419)

The January 1, 2012 revision to the National Correct Coding Initiative policy manual contains a new policy pertaining to the reporting of prostate needle core biopsies, HCPCS codes G0416-G0419.  It states:

HCPCS codes G0416-G0419 describe surgical pathology, including gross and microscopic examination, of prostate needle biopsies from a saturation biopsy sampling procedure.  CMS requires that these codes (G-Codes) rather than CPT code 88305 be utilized to report surgical pathology on prostate needle biopsy specimens only if the number of separately identified needle biopsy specimens is five or more.  Surgical pathology on four or fewer prostate needle biopsy specimens should be reported with CPT code 88305 with the unit of service corresponding to the number of separately identified biopsy specimens.

While this statement seems to apply only to biopsies obtained through the saturation biopsy process, a recent policy update by Palmetto GBA seems to have made it clear that it is Medicare’s intent to require the use of the “G” codes for all prostate procedures any time 5 or more separate specimens are reported.  It has been APS Medical Billing’s experience that when one intermediary makes an announcement such as this others will follow.

It goes without saying this will have a significant financial impact.  For example: The Medicare Physician Fee Schedule National Payment Amount for G0416-26 is $182.10 which is equivalent to 5 units of 88305-26 which has a National Payment Amount of $36.08 per unit.  For a physician practice that typically bills for more than 6 specimens for a prostate case, you will see reimbursement capped at 5.0 units.  If you bill for 12 specimens for a prostate biopsy case the Medicare reimbursement will be reduced by 58% for these cases. 

We expect continued refinement in the application of this policy.  Should you have any further questions, please feel free to contact Jan Toczynski or Holly Wolford in our Coding Department or Tom Scheanwald, President.