The Facts The January 1, 2013 revision to the National Correct Coding Initiative (NCCI) policy manual included a new policy pertaining to the reporting of prostate needle core biopsies, HCPCS codes G0416-G0419. These codes, introduced in 2009, were reported when prostate biopsy specimens were collected via prostate saturation biopsy technique. This technique traditionally results in a large number of biopsies, which prompted Medicare to establish a payment policy; reimbursing one unit of 88305 for each separately identified core, resulting in HCPCS codes being established. In 2013, HCPCS code G0416 was revised to cover 10-20 specimens; a change from 1-20 in previous fee schedules. If there are less than 10 specimens separately identified and submitted, pathologists can report 88305 times the number of specimens.
Reimbursement Analysis Even though CMS increased the number of specimens that can be separately reported from 4 to 9 (88305) in 2013, they did not significantly increase the reimbursement of G0416. The professional component (PC) of G0416 is equivalent to roughly 5 units of 88305-26. Reimbursement for the next G-Code in order, G0417 (21-40 specimens), yields approximately 9.5 times the 88305-26 payment amount, per the Medicare Physician Fee Schedule national reimbursement.
Commercial Carriers As this is only a guideline for Medicare and Medicaid patients, please continue to report 88305 for the appropriate number of separately identified specimens. APS has written a system edit to accommodate this coding change based on financial class. Patients with insurance under the CMS umbrella will be identified and the proper “G” code will be used for billing purposes. If you have additional questions, please contact your Account Manager or Account Representative.
In working through the wide variety of billing arrangements, APS found payments that we had been missing.