Management of Pathology Practices
Coding Prostate Saturation Biopsies
By Laura Edgeworth, PSA, LLC
The approval of the 2009 Medicare Physician Fee Schedule brought several changes to the Pathology community. Perhaps one of the most significant changes was the addition of four HCPCS (Healthcare Common Procedure Coding System) codes used to report the surgical pathology examination of prostate saturation biopsies to Medicare. While the Final Rule provided clarification on Medicare’s policies regarding prostate saturation biopsies, this raised additional questions in the pathology community. What is a prostate saturation biopsy? How is this procedure reimbursed? How can pathologists determine whether the specimen received was obtained by traditional methods versus prostate saturation biopsy technique?
Prostate saturation biopsy (PSB) is an alternative biopsy technique used to detect prostate cancer in high risk patients. Examples of high-risk patients include those with elevated PSA levels and a history of negative biopsies, patients with abnormal findings on previous biopsies (such as high grade prostatic intraepithelial neoplasia) or abnormal rectal exams. Since these patients have undergone traditional transrectal biopsies with negative results, some urologists are beginning to opt for saturation biopsies in an effort to diagnose cancer earlier. Clinicians hope that increasing the number of biopsies sampled can increase the possibility of detecting cancers in high-risk patients. PSB procedures are usually performed from a transperineal approach under general anesthesia, using ultrasound technology. This allows the urologist to label each core as to site and creates a map of the precise location of each biopsy.
Since the prostate saturation biopsy technique results in large numbers of biopsies (typically 30-40), Medicare needed a new means for reporting and reimbursing biopsies taken in this manner. Pathology practices billing for biopsies taken using the saturation technique must now report a single code based on the total number of biopsies received rather than coding individually for each biopsy (similar to the way flow cytometry is now reported and reimbursed). For 2009, Medicare has created the following HCPCS codes for reporting prostate saturation biopsies:
•G0416- Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 1-20 specimens
•G0417- Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 21-40 specimens
•G0418- Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 41-60 specimens
•G0419- Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, greater than 60 specimens
Under the new reporting system, the typical prostate biopsy procedure involving 30-40 biopsies would be reported using HCPCS code G0417, which has a Medicare allowable amount of $355.98
It is important to note that the addition of these new codes for reporting PSB does not change the coding of the traditional transectional ultrasound (TRUS) prostate biopsies. The final rule states that pathologists should continue to report the 88305 code for surgical pathology services unrelated to the prostate saturation method.
Pathology practices cannot rely on the number of biopsies alone to determine if they have received a PSB case. G codes are reported when the urologist performs the 55706 surgical procedure (Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance). Although pathology practices do not receive information regarding the coding of the surgical procedure itself, practices should contact their clients to request that the type of procedure performed be clearly documented on requisition forms. Without this information, it would be difficult to determine whether the specimen received was a sextant core TRUS biopsy or a 6 core transperineal saturation biopsy. Pathology practices must know the methodology of collection in order to ensure compliance with Medicare’s coding policy for prostate saturation biopsies.
The CAP discussed this issue in a conference call entitled, “Important Changes in the 2009 Physician Fee Schedule,” on December 3, 2008. An audio recording of the conference call is available for download on the CAP website at www.cap.org. The recording can be found under the heading CAP in Washington on the Advocacy webpage. Click on Audio Conferences and then “Listen to a Streaming Version” under the December 3, 2008 audio conference. Information regarding the prostate saturation biopsy discussion begins at setting 24:30.
For more information on Prostate Saturation Biopsies, please contact Leigh Polk at 800.832.5270 x 2941 or lpolk@PSAPath.com. PSA provides billing, coding, marketing, and business support services to pathologists nationwide. For more information on PSA please visit www.PSAPath.com.