Clinical Info/Hx:  Enlarged prostate. 

Date of service: 1-1-15

Gross Description
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?

Coding Prostate Biopsies

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.

Fact sheets: Policy and payment changes to the Medicare Physician Fee schedule for 2015” Media Release Database, Fact sheets, 2014 Fact sheets Items
2014 ICD 9-CM Manual (American Medical Association) pages 7, 438, 837
2015 Draft ICD 10-CM Manual (AMA) pages 5, 257, 727

This commentary does not supplant the American Medical Association’s (AMA) current listing of Current Procedural Terminology (CPT®) codes, its documentation in the annual CPT Changes publications, and other related publications from the AMA, which are the authoritative source for information about CPT codes. Please refer to your 2014 CPT Code Book, annual CPT Changes publication, HCPCS Book and Payer Bulletins for additional information, including additions, deletions, changes, and interpretations that may not be reflected in this document.    

CPT is a registered trademark of the AMA. The AMA is the owner of all copyright, trademark, and other rights to CPT and its updates. MLN Matters® is a registered trademark of the U.S. Department of Health and Human Services.

Author - Female

About the author

Beth McDevitt, CPC is Compliance - National Pathology Coding Manager, Auditing, Pathology and Laboratory of McKesson Business Performance Services