CPT 88305, 88307 - Surgical pathology billing procedure codes

Procedure Code Description


88305 Level IV surgical pathology, gross and microscopic examination…prostate needle biopsy…

88307 (Level V -surgical pathology, gross and microscopic examination)

G0416 Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method, 10-20 specimens

G0417 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, 21-40 specimens

G0418 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, 41-60 specimens

G0419 Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, >60 specimens


Surgical Pathology and Related Prostate Needle Biopsy

DESCRIPTION

Surgical pathology involves the gross and microscopic examination by surgical (e.g., dermatologists) and non-surgical providers (e.g., pathologists) of surgical or biopsy specimens. The practice of surgical pathology allows for definitive diagnosis of disease (or lack thereof) in cases where tissue is surgically removed from a patient. This is usually performed by a combination of gross (i.e., macroscopic) and histologic (i.e., microscopic) examination of the tissue, and may involve evaluations of molecular properties of the tissue by immunohistochemistry or other laboratory tests. This policy applies to all professional providers billing Current Procedural Terminology (CPT®′) or Healthcare Common Procedure Coding System (HCPCS Level II) codes on a Form CMS-1500 for multiple surgical pathology services for prostate needle biopsy


POLICY

A prostate needle biopsy commonly occurs based on the detection of elevated prostate-specific antigen (PSA) performed as part of prostate cancer screening. Typically, the initial biopsy consists of a small number of core specimens taken of the prostate. Individuals with an elevated PSA level but with a normal initial biopsy often undergo repeat biopsy evaluation. Prostate saturation biopsy, also referred to as prostate saturation needle biopsy, involves taking numerous samples of prostate tissue, typically 20 to 40 cores, in order to increase the likelihood of detecting prostate cancer in a subgroup of high-risk individuals in whom previous conventional
prostate biopsies have been negative.

CPT code 88305 describes level IV surgical pathology, gross and microscopic examination. When the operating provider or pathologist examines multiple, separate tissue samples on the same date of service for the same patient, the procedure code is reported using either multiple units or line items and may include any appropriate modifier(s). When the tissue samples are for prostate tissue, HCPCS lists procedure codes G0416-G0419 for 10 or more specimens in various increments for prostate needle biopsy. Therefore, the Health Plan will apply a frequency limit of nine units per date of service for CPT code 88305 when reported with a prostate diagnosis. When CPT code 88305 is reported in excess of nine units on the same date of service with a prostate diagnosis, the code will not be eligible for reimbursement.


Billing and Reimbursement of Prostate Biopsy Services

Effective September 1, 2012, the global reimbursement for professional pathology services for prostate biopsy codes 88305 and 88307 will be capped at nine units.


Professional pathology services must be billed as a global charge when billing for both the technical and professional components. Healthcare Common Procedure Coding System (HCPCS) code G0416 should also be considered when billing for examination of prostate biopsy samples.


Payment Edit rules

88300 (Level I -surgical pathology, gross examination only) bundles with 88302 (Level II -Surgical pathology, gross and microscopic examination), 88304 (Level III -surgical pathology, gross and microscopic examination), 88305 (Level IV -surgical pathology, gross and microscopic examination),

88307 (Level V -surgical pathology, gross and microscopic examination) and 88309 (Level VI - surgical pathology, gross and microscopic examination).


CODE RULE CODE 88300 

Redundant/Mutually Exclusive 88302
88304
88305
88307
88309

Surgical Pathology Services payment Guide from Medicare

Surgical pathology services include the gross and microscopic examination of organ tissue performed by a physician, except for autopsies, which are not covered by Medicare. Surgical pathology services paid under the physician fee schedule are reported under the following CPT codes:

88300, 88302, 88304, 88305, 88307, 88309, 88311, 88312, 88313, 88314, 88318, 88319, 88321, 88323, 88325, 88329, 88331, 88332, 88342, 88346, 88347, 88348, 88349, 88355, 88356, 88358, 88361, 88362, 88365, 88380.

Depending upon circumstances and the billing entity, the carriers may pay professional component, technical component or both.

CPT code 15734, 15732, 15740 - Muscle, mycoutaneos procedure

15570* Formation of direct or tubed pedicle, with or without transfer; trunk

15731* Forehead flap with preservation of vascular pedicle (e.g., axial pattern flap, paramedian forehead flap)

15732* Muscle, myocutaneous, or fasciocutaneous flap; head and neck (e.g., temporalis, masseter muscle, sternocleidomastoid, levator scapulae)

15734* Muscle, myocutaneous, or fasciocutaneous flap; trunk

15736* Muscle, myocutaneous, or fasciocutaneous flap; upper extremity

15738* Muscle, myocutaneous, or fasciocutaneous flap; lower extremity

15740* Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel

15756* Free muscle or myocutaneous flap with microvascular anastomosis


DEFINITIONS

Congenital Anomaly: A physical developmental defect that is present at the time of birth, and that is identified within the first twelve months of birth. Cosmetic Surgery: Defined by the American Society of Plastic Surgeons, "is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem." Functional/Physical Impairment: A physical/functional or physiological impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas:

physical and motor tasks; independent movement; performing basic life functions.


Injury: Bodily damage other than Sickness, including all related conditions and recurrent symptoms.

Microtia: The most complex congenital ear deformity when the outer ear appears as either a sausage-shaped structure resembling little more than the earlobe. It may or may not be missing the external auditory or hearing canal. Hearing is impaired to varying degrees.

Reconstructive Surgery: Defined by the American Society of Plastic Surgeons, "is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.”

Sickness: Physical illness, disease or Pregnancy. The term Sickness as used in this Certificate does not include mental illness or substance abuse, regardless of the cause or origin of the mental illness or substance abuse.


Coding Clarification

** Flaps (Skin and/or Deep Tissues) Procedures: 15570-15738

o The regions listed refer to a donor site when a tube is formed for later transfer or when a "delay" of flap occurs prior to the transfer. Codes 15732-15738 are described by donor site of the muscle, myocutaneous, or fasciocutaneous flap.

o A repair of a donor site requiring a skin graft or local flaps is considered an additional separate procedure.

o (For microvascular flaps, see 15756-15758)

o (For flaps without inclusion of a vascular pedicle, see 15570-15576)

o (For adjacent tissue transfer flaps, see 14000-14302)

o The regions listed refer to the recipient area (not the donor site) when a flap is being attached in a transfer or to a final site.

o Codes 15570-15738 do not include extensive immobilization (e.g., large plaster casts and other immobilizing devices are considered additional separate procedures).

** Other Flaps and Grafts Procedures: 15740-15777

o Neurovascular pedicle procedures are reported with 15750. This code includes not only skin but also a functional motor or sensory nerve(s). The flap serves to reinnervate a damaged portion of the body dependent on touch or movement (e.g., thumb). Repair of donor site requiring skin graft or local flaps should be reported as an additional procedure.

o Code 15740 describes a cutaneous flap, transposed into a nearby but not immediately adjacent defect, with a pedicle that incorporates an anatomically named axial vessel into its design. The flap is typically transferred through a tunnel underneath the skin and sutured into its new position. The donor site is closed directly.

o For random island flaps, V-Y subcutaneous flaps, advancement flaps, and other flaps from adjacent areas without clearly defined anatomically named axial vessels, see 14000-14302.



CPT 23472, 23470, 23474 - Arthroplasty procedure codes

CPT Code Description

23470 Arthroplasty, glenohumeral joint; hemiarthroplasty

23472 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement [e.g., total shoulder])

23473 Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component

23474 Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component

23616 Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed; with proximal humeral prosthetic replacement

SHOULDER REPLACEMENT SURGERY (ARTHROPLASTY)

CONDITIONS OF COVERAGE

Applicable Lines of Business/ Products This policy applies to Oxford Commercial plan membership.

Benefit Type General benefits package Referral Required

(Does not apply to non-gatekeeper products) No Authorization Required (Precertification always required for inpatient admission) Yes Precertification with Medical Director Review Required No Applicable Site(s) of Service

(If site of service is not listed, Medical Director review is required) Inpatient, Outpatient

BENEFIT CONSIDERATIONS

Before using this policy, please check the member specific benefit plan document and any federal or state mandates, if applicable.

Essential Health Benefits for Individual and Small Group

For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage for benefits which are deemed EHBs, the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is made on a state by state basis. As such, when using this policy, it is important to refer to the member specific benefit plan document to determine benefit coverage.

Covered ICD 10


ICD-10-PCS Code ICD-10-PCS Description

ØRRJØJZ Replacement of right shoulder joint with synthetic substitute, open approach
ØRRKØJZ Replacement of left shoulder joint with synthetic substitute, open approach
ØRREØJZ Replacement of right sternoclavicular joint with synthetic substitute, open approach
ØRRFØJZ Replacement of left sternoclavicular joint with synthetic substitute, open approach
ØRRGØJZ Replacement of right acromioclavicular joint with synthetic substitute, open approach
ØRRHØJZ Replacement of left acromioclavicular joint with synthetic substitute, open approach
ØRRJØJ6 Replacement of right shoulder joint with synthetic substitute, humeral surface, open approach
ØRRKØJ6 Replacement of left shoulder joint with synthetic substitute, humeral surface, open approach
ØRRJØJ7 Replacement of right shoulder joint with synthetic substitute, glenoid surface, open approach
ØRRKØJ7 Replacement of left shoulder joint with synthetic substitute, glenoid surface, open approach
ØRRJØØZ Replacement of right shoulder joint with reverse ball and socket synthetic substitute, open approach
ØRRKØØZ Replacement of left shoulder joint with reverse ball and socket synthetic substitute, open approach
ØRWGØJZ Revision of synthetic substitute in right acromioclavicular joint, open approach
ØRWG4JZ Revision of synthetic substitute in right acromioclavicular joint, percutaneous endoscopic approach
Shoulder Coding Reference Guide
ØRWHØJZ Revision of synthetic substitute in left acromioclavicular joint, open approach
ØRWH4JZ Revision of synthetic substitute in left acromioclavicular joint, percutaneous endoscopic approach
ØRWJØJZ Revision of synthetic substitute in right shoulder joint, open approach
ØRWJ4JZ Revision of synthetic substitute in right shoulder joint, percutaneous endoscopic approach
ØRWKØJZ Revision of synthetic substitute in left shoulder joint, open approach
ØRWK4JZ Revision of synthetic substitute in left shoulder joint, percutaneous endoscopic approach

CPT code 99251, 99252 , 99253, 99254, 99255

Procedure code and Description

99251 Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are selflimited or minor. Typically, 20 minutes are spent at the bedside and on the patient's hospital floor or unit.


99252 Inpatient consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Typically, 40 minutes are spent at the bedside and on the patient's hospital floor or unit.

99253 Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 55 minutes are spent at the bedside and on the patient's hospital floor or unit.

99254 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent at the bedside and on the patient's hospital floor or unit.

99255 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 110 minutes are spent at the bedside and on the patient's hospital floor or unit.


 Types of Consultations

CPT″ consultation codes are divided into two sections based on place of service:

A. Office or Other Outpatient Consultations:

Office or other outpatient consultations are reported with CPT″ codes 99241-99245 with no distinction between new and established patients. Consultation is appropriate in any outpatient setting including the office, emergency department, home, or domiciliary setting.

B. Inpatient Consultations:

Inpatient consultations are reported with CPT″ codes 99251-99255. The codes are used to report physician or other health care professional consultations provided to hospital inpatients, residents of nursing facilities, or patients in a partial hospital setting.


Initial and Follow-Up Consultation Services

A. Initial Consultation

1. In the hospital and nursing facility setting, the consulting physician or other qualified health care professional shall use the appropriate inpatient consultation CPT″ codes 99251-99255 for the initial consultation service. The initial inpatient consultation may be reported only once per consultant per patient per facility admission.

2. In the office or outpatient setting, the consultant should use the appropriate office or outpatient consultation CPT″ codes 99241-99245 for the initial consultation service. 3. A consulting physician or other qualified health care professional may initiate diagnostic services and treatment at the initial consultation service or may even take over the patient’s care after the initial consultation.

B. Follow-up Services

1. Ongoing management, following the initial consultation service by the consulting physician or other qualified health care professional should not be reported with consultation service codes. These services need to be reported as subsequent visits with the appropriate place of service and level of service.

2. In the hospital setting, following the initial consultation service, the subsequent hospital care CPT″ codes 99231-99233 should be reported for additional follow-up visits. In the nursing facility setting, following the initial consultation service, the subsequent nursing facility care CPT″codes 99307-99310 should be reported for additional follow-up visits.

3. In the outpatient setting, following the initial consultation service, the office or outpatient established patient CPT″ codes 99212-99215 should be reported for additional follow-up visits.

4. If an additional request for an opinion regarding the same or new problem with the same patient is received from the same or another physician or other appropriate source and documented in the medical record, the office or outpatient consultation CPT″ codes 99241- 99245 may be used again • However, if after any consultation service, the consultant then continues to care for the patient for the original condition, such follow-up services should not be reported with consultation service codes.

Medicare Guidelines for consult code 99241 - 99255 


• Follow-up visits to a consultation service in the office or other outpatient settings will be reported with the Office or Other Outpatient Established Patient codes 99212-99215.

• Beginning January 1, 2006, in a facility setting a second opinion consultation arranged through the attending physician will be reported by a physician/qualified NPP using an appropriate Initial Inpatient Consultation code when the consultation requirements are met.

• When consultation requirements are not met the Subsequent Hospital Care codes (99231-99233) in the hospital setting and the Subsequent NF Care codes (99307-99310) in the NF setting will be reported.

• In the Office or Other Outpatient setting for a second opinion evaluation, a physician/qualified NPP will use new patient codes (99201-99205) for new patients and established patient codes (99212- 99215) for an established patient, as appropriate.

• Physicians and qualified NPPs must report:

• Initial Inpatient Consultation codes (99251-99255) for an initial consultation and the inpatient hospital setting and the SNF/NF setting; and

• Appropriate Office or Other Outpatient Consultation codes (99241-99245) for and initial consultation in the office/outpatient setting.

• Following the physician’s and qualified NPP’s initial consultation service, the follow-up visits should be reported using the:

• Subsequent Hospital Care codes (99231-99233) for the inpatient hospital setting; and

• Subsequent NF Care codes (99307-99310) in the NF setting; and

• Office or Other Outpatient Established Patient codes (99212-99215) should be reported for the office/outpatient setting.



Billing with Preventive code

Preventive Medicine Services include counseling. When counseling service codes are billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.

Consult code replacement CPTs.

Medicare no longer accept consult code. Please find below the crosswalk replacement codes for consult code


CPT Consultative Services Code CPT E/M Codes for Crosswalking Modifier Required

99251 99221 (Inpatient Initial Visit, level 1) Yes, you will need to append Modifier “AI”

99252 99221 (Inpatient Initial Visit, level 1) or 99222 (Inpatient Initial Visit, level 2) Yes, you will need to append Modifier “AI”

99253 99222 (Inpatient Initial Visit, level 1) Yes, you will need to append Modifier “AI”

99254 99222 (Inpatient Initial Visit, level 2) or 99222 (Inpatient Initial Visit, level 3) Yes, you will need to append Modifier “AI”

99255 99223 (Inpatient Initial Visit, level 3) Yes, you will need to append Modifier “AI”



CPT code G0502, G0503,G0504, G0507 - Psychiatric managment

• G0502: Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of  behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements:

++ Outreach to and engagement in treatment of a patient directed by the treating physician or other qualified health care professional;

++ Initial assessment of the patient, including administration of validated  rating scales, with the development of an individualized treatment plan;

++ Review by the psychiatric consultant with modifications of the plan if recommended;

++ Entering patient in a registry and tracking patient follow-up and progress using the registry, with  appropriate documentation, and participation in weekly caseload consultation with the psychiatric consultant; and

++ Provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies.



• G0503: Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements:


++ Tracking patient follow-up and progress using the registry, with appropriate documentation;

++ Participation in weekly caseload consultation with the psychiatric consultant;

++ Ongoing collaboration with and coordination of the patient’s mental health care with the treating physician or other qualified health care professional and any other treating mental health providers;

++ Additional review of progress and recommendations for changes in treatment, as indicated, including medications, based on
recommendations provided by the psychiatric consultant;

++ Provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies;

++ Monitoring of patient outcomes using validated rating scales; and relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment.



• G0504: Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional (List separately in addition to code for primary procedure) (Use G0504 in conjunction with G0502, G0503).


Beginning in CY 2017, we are providing separate payment for BHI services furnished under models of care other than the psychiatric CoCM model, under HCPCS code G0507: Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, with the following required elements:


• Initial assessment or follow-up monitoring, including the use of applicable validated rating scales;

• Behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes;

• Facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation; and

• Continuity of care with a designated member of the care team.


G0507 is reported by the treating physician or other qualified health care professional for services furnished during a calendar month service period.

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