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Prostate Biopsies & Molecular Diagnostics Changes for 2013

Update on Prostate Biopsy HCPCS Codes (G0416-G0419)

The January 1, 2013 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.  These codes were introduced in 2009 by Medicare and were to be reported when prostate biopsy specimens were collected via prostate saturation biopsy technique. Since this technique resulted in large numbers of biopsies, Medicare wanted to update the established payment policy of reimbursing one unit of 88305 for each separately identified core, so the HCPCS codes were established.

As of January 1, 2013 CMS has revised the description of HCPCS code G0416 (surgical pathology; gross and microscopic examination for prostate needle saturation biopsy sampling, 1-20 specimens) to cover 10-20 specimens.  According to CMS, this change will “better reflect the interaction of this service, and associated RVUs, with billing for surgical pathology.”  The new guidelines in the NCCI Policy Manual: Version 19.0 regarding these HCPCS codes now states:

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

With this clarification for 2013, all saturation biopsies separately identified and submitted will be reported as follows:

• G0416-Surgical pathology, gross and micro exam for prostate needle saturation biopsy sampling, 10-20 specimens
• G0417-…………21-40 specimens
• G0418-…………41-60 specimens 
• G0419-…………greater than 60 specimens
• Example: 24 prostate saturation biopsies
Medicare/Medicaid-G0417
Commercial Carrier-88305 x 24

For all prostate needle biopsies separately identified and submitted ten or more, they will be reported as follows: 

• G0416-Surgical pathology, gross and micro exam for prostate needle saturation biopsy sampling, 10-20 specimens
• G0417-…………21-40 specimens
• G0418-…………41-60 specimens 
• G0419-…………greater than 60 specimens
• Example: 24 prostate needle biopsies
Medicare/Medicaid-G0417
Commercial Carrier-88305 x 24

If there are less than ten specimens separately identified and submitted, report 88305 times the number of specimens. 

• Example: 6 prostate needle biopsies
Medicare/Medicaid-88305 x 6
Commercial Carrier-88305 x 6

Unfortunately, even though CMS increased the number of specimens that can be separately reported as 88305 from four to nine in 2013, they did not significantly increase the reimbursement for G0416.  The 2013 Medicare Physician Fee Schedule (MPFS) payment amount for G0416-26 is still equivalent to approximately five units of 88305-26.  The 2013 MPFS payment amount for 88305-26 in Ohio, for example, is $36.03, while the payment amount for G0416-26 is $177.58.  The MPFS payment amount for G0417-26 is $341.97, which is approximately 9.5 times the 88305-26 payment amount.

As this is only a guideline for Medicare and Medicaid patients, continue to report 88305 for the appropriate number of separately identified specimens.  APS Medical Billing is prepared to accommodate this change through a system program to convert 88305 to the appropriate “G” code if the patient is a Medicare or Medicaid beneficiary. 

Should you have any further questions, please contact your Account Manager or Account Representative.

New 2013 Code for Molecular Diagnostics

Beginning January 1, 2013 CPT code 83912 (Molecular diagnostics; interpretation and report) has been deleted and replaced with G0452 (Molecular pathology procedure; physician interpretation and report).

G0452 will be reported to all insurance carriers by physicians when an interpretation and report has been performed on Tier 1 & Tier 2 molecular pathology procedures.  According to CMS, doctoral-level scientists or other appropriately-trained non-physician health care professionals are not eligible to use this code. 

While our clients work to accommodate this change in their reporting of services to us for billing, APS has made the necessary changes in our system to convert CPT code 83912 to G0452 for correct billing to the carriers.

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