This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, and outpatient facility providers billing on a UB-04 claim form or the electronic equivalent, 837i.
Surgical pathology for prostate biopsies, including gross and microscopic examinations, is covered and eligible for reimbursement consideration by the Company when the service is reported with Healthcare Common Procedure Coding System (HCPCS) code G0416. The Company does not reimburse surgical pathology for prostate biopsies when reported with Current Procedural Terminology (CPT) code 88305.
Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, utilization management/referral requirements, provider contracts, and Company policies apply.
REQUIRED DOCUMENTATION
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
BILLING REQUIREMENTS
Surgical pathology for one or more prostate biopsies obtained from the same individual, on the same date of service, by the same or different professional provider must be reported with HCPCS code G0416 and one unit of service.
