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88305 denial from Medicare- Pls Help

  1. #11
    Default Medicare
    Medical Coding Books
    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.

  2. Default
    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.

  3. #13
    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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