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Test yourself with this coding case study.

Billing a case for a prostate biopsy pathology exam can easily go sideways into fraud or underpayment if you don’t know the lay of the land. Read on for three expert tips that will help you select the proper codes and units of service to ensure audit-worthy coding — and to capture all the pay you deserve.

Tip 1: Determine the Payer

How you code prostate biopsy specimen examinations varies significantly depending on the payer. For most commercial insurances, coders turn to one primary code for prostate biopsy pathology exam: 88305 (Level IV - Surgical pathology, gross and microscopic examination … Prostate, needle biopsy …). The unit of service for this code is each separately identified prostate needle biopsy.

But Medicare has a different idea. To report a prostate biopsy pathology exam case to Medicare,  you must use HCPCS Level II code G0416 (Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method). The unit of service for this code is each prostate biopsy case, regardless of the number of separately identified prostate needle biopsies.

Tip 2: Grasp Coding and Payment Impact

When surgeons perform prostate biopsies, the pathologist typically receives multiple, separately identified specimens based on location within the organ. The specimens generally come from one of the two following surgical procedures:

• 55700 (Biopsy, prostate; needle or punch, single or multiple, any approach)
• 55706 (Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance)

The 55700 procedure, known as a standard sextant biopsy, typically samples six to 12 tissue cores. On the other hand, 55706, often referred to as a saturation biopsy, commonly samples 35 to 60 cores. For both procedures, the surgeon separately submits and carefully documents the location of each core within the prostate, meaning that each core is a separate specimen under CPT^® instructions for surgical pathology exam codes 88300-88309.

Correct coding: If the surgeon submits seven distinct prostate biopsy specimens, whether from a 55700 or 55706 procedure, you should bill the service as 88305 x 7 for non-Medicare payers, but as G0416 if the patient is a Medicare beneficiary.

Payment impact: In the preceding example, your pathologist might receive $486.78 from a commercial payer when 88305 pays $69.54 per specimen (times seven specimens). On the other hand, G0416 compensates the pathologist $354.52 for the same service of evaluating seven distinct prostate biopsies (stated payment rates based on 2025 National Medicare Physician Fee Schedule Non-Facility amount for the global service). The payment discrepancy could increase dramatically for prostate saturation biopsies with many cores.

Tip: Check individual payer rules, as some commercial insurers may also require G0416.

Final caution: There’s no way around the G0416 unit of service, which is one per date of service, regardless of the number of prostate core biopsies. Medicare enforces that limit with a Medically Unlikely Edit (MUE) of 1, and an MUE Adjudication Indicator (MAI) of 2, which identifies the edit as an absolute date-of-service MUE that you may never override with a modifier.

Tip 3: Don’t Forget Adjunct Services

Pathologists often use immunohistochemical (IHC) stains on prostate biopsy tissue specimens to distinguish prostatic adenocarcinoma from carcinoma mimics of different cell origins. These stains are special services that are separately billable.

The pathologist may use an individual IHC stain, such as AMACR (Alpha-Methylacyl-CoA Racemase), which you should report as 88342 (Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure) if it is the initial stain, or +88341 (… each additional single antibody stain procedure (List separately in addition to code for primary procedure) if it is a subsequent different stain on the same specimen.

If the pathologist uses a multiplex (cocktail) stain that combines several individually visualized antibodies, you should report the service as 88344 (… each multiplex antibody stain procedure).

Key: As you can see from the common part of the code definitions, the unit of service for codes 88341-88344 is the specimen. That means you should bill the stain service for each distinct prostate biopsy specimen that the pathologist stains and diagnoses. Even if you’re billing 1 unit of G0416 for the prostate biopsy case, you may appropriately report multiple units of the IHC stain codes.

Limits: Despite your ability to bill multiple units of IHC stains with a single unit of G0416, you still face some restrictions on the number of units you can bill based on the National Correct Coding Initiative’s (NCCI’s) MUE table, which lists the maximum number of units considered reasonable for that code. Further, the MUE for each code is listed with an MAI that provides information about whether the limit is a claim-line or date restriction, and whether you may be able to override the limit.

Here’s what the MAI indicators mean:

• MAI 1 is a claim-line edit, but you may report units more than the limit on a different claim line with a modifier, when medically necessary.
• MAI 2 is an absolute date of service edit, meaning that you should never bill more than the limit for a single date of service.
• MAI 3 is a date of service limit based on clinical benchmarks, meaning that a number above the limit would be denied, but an appeal may be possible based on a documentation of medical necessity.

Here’s how this impacts IHC coding:

• Code 88342 has an MUE of 4 with an MAI of 3
• Code +88341 has an MUE of 13 with an MAI of 3
• Code 88344 has an MUE of 6 and an MAI of 3

Focus Coding With This Example

The following case provides an example of how these rules impact what codes you should report and what payment you might expect for your pathologist’s prostate biopsy exam services.

Case: The pathologist receives 11 separately submitted prostate biopsy specimens from a single transurethral prostate biopsy procedure. The pathologist submits each specimen entirely in one cassette labeled A-K, with standard sectioning that includes four hematoxylin and eosin (H&E) slides.

For specimens B, C, D, F, G, H, and J, the pathologist additionally performs an IHC prostate triple stain (PIN-4) that contains p504S, p63, and CK5/14. This is a multiplex stain, meaning that the pathologist applies a single reagent with multiple antibodies that they can individually visualize on the slide.

Coding: The code choice for the biopsy pathology exam depends on the payer. If the patient is a Medicare beneficiary, you would report the primary code as G0416. However, you should report the case as 88305 x 11 if the patient’s commercial insurance does not recognize G0416. The H&E staining is standard and is not separately reportable.

IHC: Regardless of the pathology exam code, you should separately bill for the number of documented multiplex IHC PIN-4 stains, which is 7 units of 88344.

Caveat: When you bill 88344 x 7 in this case, you should expect a denial of 1 unit of the IHC multiplex stain because the MUE for 88344 is 6. Because the MAI for 88344 is 3, you may not use a modifier to override the MUE. However, because this is a daily limit based on a clinical benchmark, you may be able to get paid for the service on appeal if the pathologist adequately documents medical necessity for the additional stain.

Ellen Garver, BS, BA, Contributing Writer