Although Palmetto has not begun denying Prostate Biopsy claims of more than 9 units when billed with 88305 x number of Prostate Needle Biopsies billed that does not preclude Medicare Part B carriers from retroactively denying these claims and asking for refund on or offsetting the paid claims

The directive quotes the April  1, 2014 National Correct Coding Initiative Policy (NCCI) Manual which language- “ an ambiguously  worded new policy”- stating that  Medicare patient prostate biopsies, regardless of the sampling method under which the specimen was obtained, saturation biopsy or other prostate biopsy methodology, CPT code 88305 should be reported for 1 to 9 Prostate biopsy specimens and for cases for which 5 or more Biopsy specimens are received then the HCPCS Level II Code G0416 should be reported.  HCPCS Level II code language prior to the January 2012 NCCI Policy Manual was specific to “Prostate Saturation Biopsy specimens”

However, 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 and without going through requisite rulemaking and public notice requirements of the Administrative Procedures Act affecting all federal agencies. The change was made via a new policy set forth in the Jan. 1, 2012 in a language revision to the NCCI policy manual. The speculation by industry coding experts of the revised descriptor for code G0416 is that CMS intends providers and contractors to apply in practice—notwithstanding the formal descriptor for tissue from a prostate needle biopsy surgical procedure is as follows:

 G0416 Surgical pathology, gross and microscopic examination for prostate needle saturation

                biopsy sampling, regardless of biopsy approach (e.g., saturation or sextant or five region),

               for 5 to 20 specimens.

The resulting difference in revenue for a prostate biopsy case of 5 specimens virtually caps the reimbursement at 5 Prostate biopsy specimens as indicated below:

                         Virginia Palmetto Medicare 2012 reimbursement for 88305-26 x 5 = $178.75

                        Virginia Palmetto Medicare 2012 reimbursement for G0416-26      = $179.41

 

                        North Carolina Palmetto Medicare 2012 reimbursement for 88305-26 x 5 = $176.15

                        North Carolina Palmetto Medicare 2012 reimbursement for G0416-26      =$175.62

 To the best of our knowledge, formal pushback by the pathology profession and/or the laboratory industry has been absent as of the October 2012 version 12.4 of Dennis Padget’s  Pathology Service Coding Handbook and Palmetto is not currently denying Prostate cases of 5 or more specimen/units. (I believe we were all hoping that CMS and Palmetto would realize the error of their ways as is typical and rescind or revert to the previous wording as they have done so many times in the past) That being said, this does not preclude Medicare Part B carriers from retroactively denying these claims and asking for refund on or offsetting the paid claims.