Large Commercial Payer Under Pays for Prostate Biopsy Code G0416

February 12, 2015

Better look closely at your billing.  Why?  We found a large commercial payer which is not paying according to contract.

Why would this matter if you are a professional provider billing under the CMS physician fee schedule?  Well, take a look at the prostate biopsy code G0416.  Per the carrier contract, the G0416 is to be paid at 125% of the insurance fee schedule; however, the carrier has been recognizing this G0416 under the contracted amount for “all other HCPCS codes,” which represents 70% of Medicare.

Is this costing you money?  How are you going to handle this loss and renegotiate a fair payment?

According to the contract:

G0416-G0418 125% of Carrier’s designated fee schedule
All other HCPCS codes 100% of Carrier’s designated fee schedule


Who's reviewing revenue strategy with you at this time?

Are you billing all the correct CPT codes? You’d be surprised at what you might be missing. We will review your Fee Schedule/Charge Master at no cost.

That’s right. For free.

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