Clinical Info/Hx: Enlarged prostate.
Date of service: 1-1-15
All specimens are received in a formalin container labeled with the patient's name, medical record number, and site designation. Each specimen consists of cylindrical pieces (cores) of tan tissue, measuring less than 0.1 cm in diameter, and up to 1.6 cm in length.
Final Microscopic Diagnosis:
A. Left base: Benign prostatic tissue with an area of chronic inflammation.
B. Left lateral: Benign prostatic tissue with an area of chronic inflammation.
C. Left apex: Benign prostatic tissue.
D. Right base: Benign prostatic tissue with acute and chronic inflammation.
E. Right lateral: Benign prostatic tissue with severe acute and chronic inflammation.
F. Right apex: Benign prostatic tissue with severe acute and chronic inflammation.
Which procedure and diagnosis codes should be assigned for this scenario?
Since this is a Medicare patient and the date of service (DOS) is Jan. 1, 2015, only one unit of HCPCS code G0416 can be reported. Based on the 2015 Physician Fee Schedule Final Rule, effective Jan. 1, 2015, CMS finalized its proposal to delete HCPCS codes G0417, G0418, and G0419. This decision results in ALL prostate biopsies, regardless of the number of samples, to be assigned the single code G0416 as one unit of service. CPT code 88305 will no longer be used for Medicare prostate biopsy samples.
Coding in ICD-9 and ICD-10 requires two codes for this scenario because there is no single code that encompasses both acute and chronic prostatitis. The Alphabetic Index for Prostatitis separates the subentries of acute and chronic at the same indentation level. Therefore, both the acute and chronic codes are required, and sequence the acute code first.