Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Title:

Reimbursement of Surgical Pathology Services for Prostate Biopsy

Policy #:

MA00.058

Policy

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

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.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, surgical pathology, including gross and microscopic examinations, for prostate biopsies is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

Refer to the Cross References section in this policy for additional information on services included in capitation.

Description

As outlined in this policy, surgical pathology for prostate biopsies, including gross and microscopic examinations, are used to help identify prostate cancer in high-risk individuals.

References

Centers for Medicare & Medicaid Services (CMS). National Correct Coding Initiative Policy Manual. Chapter XII: Supplemental Services. [CMS Web Site]. 1/01/2022. Available at: https://www.cms.gov/files/document/chapter12hcpcscodesa0000-v9999final11.pdf. Accessed: November 07, 2025.

Coding

CPT Procedure Code Number(s)

THE FOLLOWING PROCEDURE CODE IS NOT ELIGIBLE FOR REIMBURSEMENT WHEN REPORTED FOR SURGICAL PATHOLOGY OF PROSTATE BIOPSIES (CPT CODES 55705, 55706 55707, 55708, 55709, 55710, 55711, 55712, 55713, 55714, 55715)

88305

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

G0416

Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA00.058:

03/02/2026

This version of the policy will become effective 03/02/2026.

The following new policy has been developed to communicate the Company's
reimbursement position and billing requirements for surgical pathology for prostate biopsies, including gross and microscopic examinations.

Version Effective Date:

3/2/2026

Version Issued Date: