A prostate biopsy is a procedure to remove samples of suspicious tissue from the prostate. The prostate is a small, walnut-shaped gland in men that produces fluid that nourishes and transports sperm.
During a prostate biopsy a needle is used to collect a number of tissue samples from prostate gland. The procedure is performed by a doctor who specializes in the urinary system and men’s sex organs (urologist).
Purpose of Prostate Biopsy
A prostate biopsy is used to detect prostate cancer. Doctors may recommend a prostate biopsy if:
- A PSA test shows levels higher than normal for your age.
- If finds lumps or other abnormalities during a digital rectal exam.
- If had a previous biopsy that was normal, but still have elevated PSA levels.
- A previous biopsy revealed prostate tissue cells that were abnormal but not cancerous.
Preparation of Prostate Biopsy
- Take a urine sample to analyze for a urinary tract infection. If find any type of urinary tract infection, then prostate biopsy will be postponed and treat with antibiotic.
- Stop taking medication that can increase the risk of bleeding — such as warfarin (Coumadin), aspirin, ibuprofen, and certain herbal supplements — for several days before the procedure.
- Do a cleansing enema at home before biopsy appointment.
- Take antibiotics 30 to 60 minutes before prostate biopsy to help prevent infection from the procedure.
ICD-10 Use in Prostate Biopsy
The ICD-10 codes are broken down as follows:
- N40 is the primary descriptor for enlarged prostate – benign prostatic hyperplasia.
- 4th digit of “1” defines lower urinary tract symptoms (LUTS), and directs the coder to use an additional code for the associated symptoms, when specified.
- R33 is the primary descriptor for retention of urine.
- 4th digit of “8” defines the urinary retention as “Other”, and includes an instructional note to code first, if applicable, any causal condition such as: enlarged prostate (N40.1).
CPT Codes & Guideline for Coding
- HCPCS codes G0416-G0419 describe surgical pathology, including gross and microscopic examination, of prostate needle biopsies from a saturation biopsy sampling procedure.
- “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.”
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.
G0416– Surgical pathology, gross and micro exam for prostate needle saturation biopsy sampling 1-20 specimens.
G0417- ” 21-40 specimens.
G0418- ” 41-60 specimens.
G0419- ” greater than 60 specimens.
NOTE : G0416 to Medicare for TURP specimens. However, per the code descriptor, (Surgical pathology, gross and microscopic examinations for prostate needle biopsy, any method), G0416 is specific to needle core biopsy samples, and not appropriate for TURP specimens.
As of January 1, 2012 CMS has issued new guidance in the NCCI Policy Manual regarding these HCPCS codes. It states:
HCPCS codes G0416-G0419 describe surgical pathology, including gross and microscopic examination, of prostate needle biopsies from a saturation biopsy sampling procedure. CMS requires that these codes rather than CPT code 88305 be utilised to report surgical pathology on prostate needle biopsy specimens only if the number of separately identified needle biopsy specimens is five or more. Surgical pathology on four or fewer prostate needle biopsy specimens should be reported with CPT code 88305 with the unit of service corresponding to the number of separately identified biopsy specimens.
The Medicare Physician Fee Schedule National Payment Amount for G0416-26 is $182.10 which is equivalent to 5 units of 88305-26 which has a National Payment Amount of $36.08 per unit. For a physician practice that typically bills for more than 6 specimens for a prostate case, you will see reimbursement capped at 5.0 units. If you bill for 12 specimens for a prostate biopsy case the Medicare reimbursement will be reduced by 58% for these cases.