August 21, 2012

Palmetto Medicare Part B policy update on prostate biopsy coding

On August 7, 2012, Palmetto GBA, a Medicare contractor, issued a policy update entitled “Prostate Biopsy Coding/Billing Guidelines." This Palmetto policy references a National Correct Coding Initiative (NCCI) update that was published in January 2012, and appears to be the first instance of a Medicare contractor confirming its adoption of the January 2012 NCCI update.

The January 2012 NCCI update provides that:

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

When this January 2012 NCCI update appeared, there was no contemporaneous publication by CMS or any of the Medicare contractors confirming its general adoption by the Medicare program. Moreover, there has been confusion as to whether NCCI intended the G codes to be utilized only where the biopsies were collected from a saturation biopsy technique, or regardless of the collection methodology. NCCI’s medical director has informed some private sources that the G codes should be used any time there are five or more prostate biopsy specimens, regardless of collection methodology. The August 7, 2012 Palmetto GBA policy adopts the NCCI update, explaining that the number of prostate biopsy specimens (regardless of collection technique) that can be reported with CPT Code 88305 is limited to four units per case, and the evaluation of five or more prostate biopsies must be reported using the G codes.

It will be important for providers in jurisdictions covered by Palmetto GBA to begin billing and collecting in accordance with this policy update. Providers in other Medicare jurisdictions may wish to confirm with their own Medicare contractors as to each contractor’s policy with respect to the coding of prostate biopsies. As of August 15, 2012, it does not appear as though any other Medicare contractor has published a specific policy on the issue.

For more information, please contact:

Jane Pine Wood


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