prostate G0416?

[musom]

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I thought I read somewhere that prostate G codes had been removed from 2015 onward. I had been coding multi-part prostate biopsies as individual 88305's, but just noticed that the billers/coders had been correcting my 88305's to one G0416. So is G0416 still valid for all prostate biopsies, not matter how many parts? Or was I correct in using multiple 88305's?

 

[LADoc00]

I thought I read somewhere that prostate G codes had been removed from 2015 onward. I had been coding multi-part prostate biopsies as individual 88305's, but just noticed that the billers/coders had been correcting my 88305's to one G0416. So is G0416 still valid for all prostate biopsies, not matter how many parts? Or was I correct in using multiple 88305's?

Depends. Non-CMS payors do not recognize G-codes as they are governmental codes.

All CMS prostate biopsies from one to infinity now use G0416. There is also a maximum number individual billed IHC codes that can be used with that as well. I believe it is a 6 limit.

 

[musom]

Thanks. I wasn't aware there was an IHC cap. 👎

 

[LADoc00]

Thanks. I wasn't aware there was an IHC cap. 👎

yup CMS and United Health I believe both have one.

 

[coroner]

I believe it is a 6 limit.

CMS cap for reimbursement for IHC cocktails in prostate specimens is 88344x5

The above is correct that 88305 is for private insurers. G0416 is for Medicare only. Your coders are changing it whenever they notice the pt. has Medicare, but that's not your responsibility to check, although you could. I don't know any pathologist that double checks the pt's insurance before issuing CPT codes, it would be too much of a time waste and that's what coders are for.

There was a thread on PIN-4 codes a little while ago which mentions some of the aforementioned changes and you may find interesting

http://forums.studentdoctor.net/threads/anyone-else-getting-fleeced-on-the-new-pin-4-codes.1144830/

Btw, nice to see you two kissed and made up...