New professional reimbursement policy: Surgical Pathology and Related Prostate Needle Biopsy

Effective November 19, 2014, Anthem Blue Cross and Blue Shield of Indiana, Kentucky, Missouri, Ohio and Wisconsin will adopt a new professional reimbursement policy titled Surgical Pathology and Related Prostate Needle Biopsy. CPT® code 88305 describes level IV surgical pathology, gross and microscopic examination. When the operating provider or pathologist examines multiple, separate tissue samples on the same date of service for the same patient, the procedure code is reported using either multiple units or line items and may include any appropriate modifier(s). When the tissue samples are for prostate tissue, HCPCS lists procedure codes G0416-G0419 for 10 or more specimens in various increments for prostate needle biopsy. Therefore, the Health Plan will apply a frequency limit of nine units per date of service for CPT code 88305 when reported with a prostate diagnosis. When CPT code 88305 is reported in excess of nine units on the same date of service with a prostate diagnosis, the code will not be eligible for reimbursement.