Procedure Code Description
88305 Level IV surgical pathology, gross and microscopic examination…prostate needle biopsy…
88307 (Level V -surgical pathology, gross and microscopic examination)
G0416 Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method, 10-20 specimens
G0417 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, 21-40 specimens
G0418 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, 41-60 specimens
G0419 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, >60 specimens
Surgical Pathology and Related Prostate Needle Biopsy
DESCRIPTION
Surgical pathology involves the gross and microscopic examination by surgical (e.g., dermatologists) and non-surgical providers (e.g., pathologists) of surgical or biopsy specimens. The practice of surgical pathology allows for definitive diagnosis of disease (or lack thereof) in cases where tissue is surgically removed from a patient. This is usually performed by a combination of gross (i.e., macroscopic) and histologic (i.e., microscopic) examination of the tissue, and may involve evaluations of molecular properties of the tissue by immunohistochemistry or other laboratory tests. This policy applies to all professional providers billing Current Procedural Terminology (CPT®′) or Healthcare Common Procedure Coding System (HCPCS Level II) codes on a Form CMS-1500 for multiple surgical pathology services for prostate needle biopsy
POLICY
A prostate needle biopsy commonly occurs based on the detection of elevated prostate-specific antigen (PSA) performed as part of prostate cancer screening. Typically, the initial biopsy consists of a small number of core specimens taken of the prostate. Individuals with an elevated PSA level but with a normal initial biopsy often undergo repeat biopsy evaluation. Prostate saturation biopsy, also referred to as prostate saturation needle biopsy, involves taking numerous samples of prostate tissue, typically 20 to 40 cores, in order to increase the likelihood of detecting prostate cancer in a subgroup of high-risk individuals in whom previous conventional
prostate biopsies have been negative.
CPT code 88305 describes level IV surgical pathology, gross and microscopic examination. When the operating provider or pathologist examines multiple, separate tissue samples on the same date of service for the same patient, the procedure code is reported using either multiple units or line items and may include any appropriate modifier(s). When the tissue samples are for prostate tissue, HCPCS lists procedure codes G0416-G0419 for 10 or more specimens in various increments for prostate needle biopsy. Therefore, the Health Plan will apply a frequency limit of nine units per date of service for CPT code 88305 when reported with a prostate diagnosis. When CPT code 88305 is reported in excess of nine units on the same date of service with a prostate diagnosis, the code will not be eligible for reimbursement.
Billing and Reimbursement of Prostate Biopsy Services
Effective September 1, 2012, the global reimbursement for professional pathology services for prostate biopsy codes 88305 and 88307 will be capped at nine units.
Professional pathology services must be billed as a global charge when billing for both the technical and professional components. Healthcare Common Procedure Coding System (HCPCS) code G0416 should also be considered when billing for examination of prostate biopsy samples.
Payment Edit rules
88300 (Level I -surgical pathology, gross examination only) bundles with 88302 (Level II -Surgical pathology, gross and microscopic examination), 88304 (Level III -surgical pathology, gross and microscopic examination), 88305 (Level IV -surgical pathology, gross and microscopic examination),
88307 (Level V -surgical pathology, gross and microscopic examination) and 88309 (Level VI – surgical pathology, gross and microscopic examination).
CODE RULE CODE 88300
Redundant/Mutually Exclusive 88302
88304
88305
88307
88309
Surgical Pathology Services payment Guide from Medicare
Surgical pathology services include the gross and microscopic examination of organ tissue performed by a physician, except for autopsies, which are not covered by Medicare. Surgical pathology services paid under the physician fee schedule are reported under the following CPT codes:
88300, 88302, 88304, 88305, 88307, 88309, 88311, 88312, 88313, 88314, 88318, 88319, 88321, 88323, 88325, 88329, 88331, 88332, 88342, 88346, 88347, 88348, 88349, 88355, 88356, 88358, 88361, 88362, 88365, 88380.
Depending upon circumstances and the billing entity, the carriers may pay professional component, technical component or both.
