Urology Coding Alert

Question: Medicare denied our claim for prostate biopsies; we billed 14 units of 88305 since our in-house pathologist examined 14 specimens. What should we have done differently?

Wyoming Subscriber

Answer: Current Medicare guidelines state that you should bill HCPCS code G0416 (Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method) for prostate biopsies. You should report this code only once regardless of the number of specimens taken.

However, private payers will still accept CPT^® code 88305 (Surgical pathology, gross and microscopic examination) billed for each biopsy core. Other major insurers might allow for either G0416 or 88305. Verify the specific payer’s guidelines before submitting the claim so you can code and be paid correctly.