New HCPCS: Prostate Saturation Biopsies

The 2009 Medicare Physician Fee Schedule Final Rule published by CMS last month included the addition of four new HCPCS (Healthcare Common Procedure Coding System) codes used to report the surgical pathology examination of prostate saturation biopsies.  It is important to note that these new codes apply to a relatively new technique that is not widely used.  This technique should NOT be confused with the traditional transrectal ultrasound (TRUS) biopsy procedure, and the Final Rule clearly states that pathologists are to continue to report CPT code 88305 for surgical pathology services unrelated to the prostate saturation biopsy.

Prostate saturation biopsy (PSB) is an alternative biopsy technique utilized by urologists to help detect prostate cancer in certain high risk patients.  These patients typically have elevated PSA levels with a history of negative biopsies, abnormal findings on previous biopsies (ex., 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 PSB.  Clinicians hope that increasing the number of biopsies sampled can increase the possibility of detecting cancers in high-risk patients.  It is not uncommon for the typical PSB procedure to result in 30 or more biopsies.  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 the cancer.

Because the PSB technique results in a larger number of biopsies than typically removed via the TRUS procedure, Medicare determined a need to review the current payment policy of reimbursing for each separately identified core.  CMS determined that it is inappropriate to continue reporting CPT code 88305 for biopsies removed by PSB method and Medicare states in the Final Rule that codes HCPCS codes G0416-G0419 will result in more accurate payment for the pathology services related to the 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 

In a recent audio conference hosted by the College of American Pathologists (CAP), Dr. George Kwass, chair of the CAP Economic Affairs Committee, explained that pathologists should report the new G codes only when the urologist performs the 55706 surgical procedure (Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance).  Although pathologists often do not receive information regarding the coding of the surgical procedure itself, it is important in light of these changes for pathologists to contact referring urologists 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 TRUS biopsy or a 6 core transperineal saturation biopsy.  This new policy will have no effect on the coding of traditional TRUS biopsy specimens and it is important to note that PSBs are rarely seen in the practice setting.

An audio recording of the conference call is available for download on the CAP website at www.cap.org.  The recording can be found on the Advocacy webpage.  Information regarding the prostate saturation biopsy discussion begins at setting 24:30.