Case Study: Prostate Biopsy Billing Issues

June 7, 2022

Background:

Prostate Biopsies have seen a change in the way that billing can code and get reimbursed. 

Medicare no longer pays 88305 for prostate needle biopsies, and the appropriate code for Medicare is G0416 for all prostate needle biopsies, regardless of the number of biopsies/cores. The new definition of G0416 (Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method) reflects this change.

However, many plans continue to reimburse for the 88305 when billed with multiple units. 

Issue identified:

BCBS SC does not currently have a policy that requires G0416 to be billed. Therefore, 88305x with the appropriate number of units is the correct way to submit for a prostate biopsy. The client was missing additional revenue because billing was adjusting off unpaid units instead of appealing. 

Resolution:

Vachette identified through an audit that although the appropriate coding and units had been submitted, BCBS SC had an incorrect edit in their system limiting the number of units that were payable. 

Not only was the issue resolved to reprocess 95 claims for an additional payment of $70,000, but the payor’s system also was corrected so that claims would pay correctly moving forward and the client would not continue to have underpaid claims.

Why do we audit?

Vachette completes a quarterly audit for all of our full-scope clients to ensure that processes are tight, well defined, and effectively communicated. 

Our audit process includes a thorough analysis of the revenue cycle, from charge capture to 100% adjudication (either payment, adjustment, or write off) – determining if the process to 100% adjudication is not only done correctly from an accounting standpoint, but compliantly.

Let us know how we can serve you! Contact Sheila Lazarus, BD Manager, RCM Solutions, at sheila.lazarus@lighthouselabservices.com or by calling 517-486-4262. 

Or feel free to fill out our contact form to schedule a free consultation!

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