Wiki 88305 denial from Medicare- Pls Help

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Stensland1982

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We have recently recieved a denial from Medicare. We billed an 88305 with 14 units. We have an in-house path lab. And our pathologist did 14 units of a prostate biopsy. I could not find any specific rules about the units. Does anyone know the specifity to cpt: 88305 and if there is a max to how many units can be billed?

88305- 14 units
 
We did bill it: 88305 X14
I just couldnt find any specific rule or where to even look. Looked in the CPT book and on CMS website and CAHABA website. We are kind of at a dead end
 
Medicare created 4 "G" codes for prostate needle saturation biopsy sampling. These codes are broken down by the number of specimens obtained. If this was your method, I would look at G0416-G0419.

G0416 is for 1-20 specimens.
 
Medicare has unpublished MUE (Medically Unlikely Edits) and some of the most common pathology CPT's are in the unpublished edits. We refer to them as black-box edits. I had an 88305 X14 come back to me today from a biller working denials. I suggested she appeal it to Medicare with the report. If you can figure out the magic number (they pay for X6, but deny X7), you can split the lines and bill up to the unpublished MUE amount on one line and then the remainder on a second line using 59 modifier. This will save back-end appeals and payment delay.
 
14 prostate biopsies does seem "medically unlikely." I had over a hundred skin biopsies once that went through with no problem, so maybe the dx is triggering something. Please make sure this is not a needle saturation bx, in which case the HCPCS code would apply. Otherwise, you will have to appeal with the report.

Pam Dines makes an excellent point.
WK
Pathology Coding Blog
 
88305

I just called Medicare (Noridian) I was able to get the max unit's per line for 88305. Per Medicare, you can bill 7 units per line item. Each additional line billed use modifier 59.
 
G0416

Medicare requires you to code the G0416, G0417 etc. from the HCPCS codes. Yes, says it is for the saturation technique. No, they don't seem to care. You must use the G0416 whether it is saturation technique or not per NCCI edits. According to Dennis Padget, the pathology lab coding guru, "CMS effectively revised the descriptor on Jan. 1, 2012, although it did so without advance notice or publishing a formal revision to the descriptor anywhere." We have been waiting for a clarification from Medicare for about a year or more.

Here is what the descriptor should say,
"G0416 Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, regardless of biopsy approach (e.g., saturation or sextant or fiveregion), 10 to 20 specimens."

So, if you have 10 or less biopsies on a prostate:
88305 x # of prostate biopsies
For example 88305 x 6

If you have 10 or more biopsies on a prostate:
14 biopsies = G0416 x 1

You will only be reimbursed for 6 or 7 biopsies.

Also, you can only charge the 88342 on immunostains per stain rather than per antibody even if it is a prostate cocktail stain.

Hope this helps.
 
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we bill for prostate biopsies using the 88305...when medicare denies that many units we just send in reconsideration form with path reports and it gets paid...i have played around with the units and it seems medicare will pay 7 of them, so i usually break them up with 7 on first line then whatever on next line with 59 modifier and it gets paid.
 
Medicare

When billing Medicare for a prostate saturation biopsy you need to bill with the G code. We have researched the use of modifier 59 and came up with the following information. You cannot split the 88305 by quantity and add the modifier 59, this would be using the modifier to bypass edits. Modifier 59 is used for distinct procedural services. Modifier 59 states that "documentation must support a different session, different procedure or surgery, different size or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. When a prostate biopsy is done it is done in the same session, same procedure, same organ, and same excision and therefor does not qualify for the modifier 59. I hope this helps and if someone has information that contradicts what we have found please let me know. :)
 
I agree with Junebug777.

My office and I have done extensive research on the prostate biopsies. We came to the conclusion that the G code is what CMS intends for us to use with Medicare patients. The G code is the most compliant choice in this case. The 59 modifier is bypassing the edits.
 
I used to bill prostate biopsies and the normal testing is for 12 units. However, sometimes we did 13 and 14 and the claims were initially denied but I appealed them with the medical records and from what I can remember we did receive payment from Medicare as well as other payors.

Melissa Harris, CPC
 
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