Reimbursement Policy updates for 88305

For dates of service on or after November 24, 2014, Empire BCBS will apply a frequency limit of nine units for level IV surgical pathology code 88305 when reported with a prostate diagnosis. HCPCS lists procedure codes G0416-G0419 for surgical pathology of 10 or more prostate needle biopsy specimens; therefore, they will deny 88305 when reported with 10 or more specimens with a prostate diagnosis. The appropriate HCPCS code should be reported when the number of prostate needle biopsy specimens is greater than or equal to 10. For claims processed on or after August 18, 2014 Empire BCBS have documented that modifier 59 will not override the mutually exclusive edit for procedure code 88305 when reported with procedure codes G0416-G0419.