The Latest On Coding for Prostate Biopsies

February 11, 2013

The latest word from CMS on how to code prostate biopsies seems designed to let us know that this change is here to stay. (Remember this actually started last January with a CMS notice that required a special code for 88305 x 5 to be billed as G0416.

Now in January of 2013, the National Correct Coding Initiative (NCCI) policy manual was updated to include the HCPCS codes G0416-G0419.  Simply put, this is a sliding fee schedule built on the number of 88305’s performed on prostate needle biopsies.  This means 88305 is billed out as normal up to nine  specimens for these cases.  Then these codes come into play.
•    10-20 specimens are billed as G0416
•    21-40 specimens are billed as G0417
•    41-60 specimens are billed as G0418
•    60+ are billed as G0419

Please note this is only for prostate needle biopsy cases.
This is only for government carriers.  Commercial carriers are not billed this way.

So far we are seeing billers bill these cases in various ways.  Some billers claim that this is not applicable for their Medicare intermediary.  This may be true as every government entity seems to interpret these directions differently.

Our recommendation is to have your biller follow the NCCI policy as we have already heard of Medicare asking for refunds for these cases that are billed otherwise.

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