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Thread: 88305 denial from Medicare- Pls Help

  1. #1

    Question 88305 denial from Medicare- Pls Help

    AAPC: Back to School
    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

  2. #2


    Did you bill it 88305 x 14?

    I think w/ Medicare you have to do line-by line w/ mod 76

  3. #3


    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

  4. #4
    Join Date
    Apr 2007
    North Carolina


    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.

  5. #5


    Medicare has unpublished MUE (Medically Unlikely Edits) and some of the most common pathology CPT's are in the unpublished edits.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 If you can figure out the magic number (they pay for X6, but deny X7), you can split the lines and bill up to the unpublished MUE amount on one line and then the remainder on a second line using 59 modifier.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.

  6. #6
    Join Date
    Apr 2007
    New Orleans, LA


    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.
    Pathology Coding Blog

  7. #7

    Default 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.

  8. #8
    Join Date
    Apr 2007


    I had this same issue the other day but medicare told us we can only bill up to 12 88305's per line.

  9. #9

    Default 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.
    Last edited by BlakeCarswell82; 12-02-2013 at 02:04 PM.

  10. #10
    Join Date
    Apr 2007
    Greater Pittsburgh


    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.

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