The Painters clear up confusion surrounding coding for prostate needle biopsy, and also discuss split billing for urodynamics testing.
My physician performed a prostatic needle biopsy recently in which he only took nine specimens instead of the usual 12. How should I bill for these specimens? A friend tells me that I should be using G0416. However, I thought this code was for more than 10 specimens. Also, the CPT code 88305, the code for a single specimen, still shows that it is an active paying code when I looked it up on AUACodingToday.com I am confused.
Your friend is correct. Prostate biopsies were “separated” from other surgical specimens listed in 88305, even though they are still listed in the CPT code for 2015. Medicare no longer pays 88305 for prostate needle biopsies. G0416 is now the appropriate code for all prostate needle biopsies regardless of the number of biopsies/cores. The new definition of G0416 (Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method) reflects this change.
We mistakenly added to the confusion in our December 2014 column (“2015 final rule reflects shift from fee for service,” page 28), where we wrote: “Medicare has decided to eliminate all the G codes for prostate biopsies and revise code G0416 to be reported for all biopsies over 10 specimens.”
The correct statement should have been: “Medicare has decided to combine reporting of prostate biopsies regardless of number of specimens under revised code G0416. 88305 should not be used for the analyses of prostate biopsies for Medicare patients with dates of service on or after Jan. 1, 2015.” We apologize for this error.
I am considering making an investment in a small company that provides outsourced urodynamic studies whereby the company sends a nurse and urodynamic equipment to the physician’s premises, the study is conducted, the results are loaded into the company’s proprietary software, and the results are delivered to the physician-usually an obstetrician/gynecologist, urologist, or urogynecologist.
This company takes advantage of split billing and appears to deliver very high-quality services using the best equipment. The company bills the physician directly and in turn the physician bills Medicare/Medicaid/insurance directly using split billing, with over 100 clinics/practices using this process.
However, in some of my due diligence, some physicians I have spoken with raised a concern that Medicare/Medicaid might do away with such split billing that allows for such a study to be outsourced to the company. Is this a valid concern? Are there any caveats of urodynamic split billing to look out for as it relates to this outsourcing arrangement?
If the physician has a contract with an outside entity to perform urodynamics in their office, the physician can legally charge for the test.
If the test is performed on one day and the physician reads the test on another day, the technical component of the test is billed on the date performed and the professional component should be billed on the day the test is read by the physician. Both components should be paid by Medicare.
Some private payers do not pay for “split billing” (billing for the technical component on a different day than reporting the professional component), insisting that the physician charge for the complete test without splitting into technical and professional components. For those payers, the test, without modifiers, should be charged on the day it was performed.
Note: At this point there is not a payment differential for billing the services separately for the majority of payers.
We are not aware of any attempt by Medicare to change these rules. However, we have heard talk of overutilization of these tests and caution you to be certain that you have clear, documented pathways to determine medical necessity for each test.
We will further caution you to make sure that you are compliant with anti-kickback laws.
Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at UT@advanstar.com. Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.
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