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Prostate Biopsy Coding and NCCI Rules for 2012
The Centers for Medicare & Medicaid Services (CMS) publishes coding guidance for services related to their National Correct Coding Initiative (NCCI) on an annual basis, generally in October of each given year. The update to this manual for calendar year 2012 was published and contains significant changes as it relates to the Healthcare Common Procedure Coding System (HCPCS) codes G0416-G0419 — Prostate Needle Saturation Biopsies.
Since the introduction of these “G” codes back in October 2009, the industry guidance was to apply the “G” code(s) for prostate biopsies only when the surgical procedure used for sample collection was by “transperineal” approach method, specifically the surgical procedure code CPT® 55706 (Biopsies, prostate, needle, transperineal, stereotactic template-guided saturation sampling, including imaging guidance). When the surgeon used this surgical approach the individual specimens submitted to pathology for evaluation were to be coded with the “G” code series for Medicare and Medicaid patients. The 2012 version of the NCCI Manual was updated to reflect a different approach to the coding for these services.
The 2012 NCCI Manual now states:
HCPCS codes G0416-G0419 describe surgical pathology, including gross and microscopic examination, of prostate needle biopsies from a saturation biopsy sampling procedure. CMS requires that these codes rather than CPT® code 88305 be utilized to report surgical pathology on prostate needle biopsy specimens 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.
Since the verbiage in the NCCI Manual was silent to the surgical procedure approach for collection of the specimens, it was unclear as to whether these new instructions would relate to only the transperineal approach for collection of the specimens or to any surgical procedure approach for that collection. The NCCI CMS contractor, Correct Coding Solutions, LLC, was contacted as well as one of the CMS Medicare Administrative Contractor (MAC) and asked to confirm whether the surgical procedure used to obtain the biopsy specimen should be taken into consideration when assigning either the “G” codes, or CPT® 88305. The CMS contractors both responded stating that the surgical procedure used to obtain the specimens does NOT have any relation to the coding direction given in the 2012 NCCI guidelines. They confirmed that the total number of specimens submitted for pathology evaluation was the determining factor when selecting the code. They reaffirmed that when four or less samples were submitted, they were to be coded with CPT® 88305, and if five or more biopsies were submitted, they were to be coded with the “G” code series based on the total number of separately submitted specimens.
While CMS has yet to correct the “G” code description for “G0416,” which continues to state that code is for 1 to 20 samples collected for saturation biopsies, the specific coding instructions from CMS via the NCCI and MAC contractors is essentially 5 to 20 samples for any prostate biopsy is assigned HCPCS G0416. This adds to the confusion.CMS should correct the descriptor for HCPCS G0416 if they are to maintain this new coding guideline.
For example, if 12 separately submitted prostate biopsy samples were received from a Medicare or Medicaid patient, the correct code assignment is G0416. If only four separately submitted prostate biopsy samples were received, the correct code assignment is CPT® 88305x4. This is true regardless of any surgical procedure used to obtain the specimens.
Assuming the industry is unable to deter CMS from their decision on this coding determination, providers may see a significant reduction in the payment for prostate biopsy testing when samples exceed four specimens. The bottom line is that the codes are now assigned based on the total number of specimens submitted regardless of the surgical procedure used for collection of those samples for Medicare and Medicaid patients.
NCCI Coding Manual, Chapter 10, Revision Jan. 1, 2012
Rick Oliver, JD, CHCO, CPC, MT(ASCP)
Compliance – Pathology and Laboratory
McKesson Revenue Management Solutions