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Daily Maximum Units for Surgical Pathology and Microscopic Examination

Reimbursement Policy:
Daily Maximum Units for Surgical Pathology and Microscopic Examination

Effective Date:
February 25, 2019

Purpose:
Provide guidelines for Daily Maximum Units for Surgical Pathology and Microscopic Examination services when appropriately billed by professional providers.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • ITS Home In-Network
  • FEP
  • SHBP non MA

All Insured Individual, Commercial medical plans, and Medicare Advantage Plans, are included.

ASO accounts will be included as an Opt-In option for additional claims editing on an account-by-account basis

Policy:
Procedure code 88305 (Level IV - Surgical pathology, gross and microscopic examination) includes different types of biopsies. Diagnosis of malignancies and inflammatory conditions frequently requires numerous biopsies of a particular organ or suspicious site. To allow for multiple biopsies for investigation and diagnosis of certain disease entities, Horizon BCBSNJ shall allow additional maximum unit editing for procedure code 88305 based upon specified diagnoses as provided below:

For the following prostate conditions, up to a maximum of twelve (12) units of 88305 shall be considered for reimbursement for the same patient on the same date of service:

  • Benign neoplasm of prostate (ICD-10 code D29.1)
  • Elevated prostate specific antigen [PSA] (ICD-10 code R97.2-R97.21)
  • Enlarged prostate, inflammatory diseases of prostate or other and unspecified disorders of prostate (ICD-10 codes N40-N41.9, N42.0-N42.39)
  • Malignant neoplasm of prostate (ICD-10 codes C61, D07.5, D40.0)

For the following gastrointestinal conditions, up to a maximum of eight (8) units of 88305 shall be considered for reimbursement for the same patient on the same date of service:

  • Malignant neoplasm of colon (ICD-10 codes C18-C18.9)
  • Malignant neoplasm of rectum, rectosigmoid junction, and anus (ICD-10 codes C19, C20-C21.8)
  • Benign neoplasm of colon (ICD-10 codes D12.0-D12.6, K63.5)
  • Benign neoplasm of rectum and anal canal (ICD-10 codes D12.7-D12.9,)
  • Carcinoma in situ of digestive organs (ICD-10 codes D01.0-D01.3)
  • Chronic atrophic gastritis (ICD-10 codes K29.4-K29.41)
  • Microscopic colitis (ICD-10 codes K52-K52.9)
  • Neoplasm of uncertain behavior of digestive organs (ICD-10 codes D37.3-D37.5, D37.8, D37.9)
  • Neoplasms of unspecified nature, digestive system (ICD-10 code D49.0)
  • Regional enteritis (ICD-10 codes K50.1-K50.919)
  • Ulcerative colitis (ICD-10 codes K51.00, K51.919)
  • Unspecified chronic gastritis (ICD-10 codes K29.5-K29.51)
  • A maximum of four (4) units of 88305 shall be considered for reimbursment for all other diagnoses not listed above for the same patient on the same date of service.

Procedure
Horizon BCBSNJ shall deny 88305 for any services greater than 12 units and including a prostate diagnosis listed above.

Horizon BCBSNJ shall deny 88305 for any services greater than eight (8) units and including a gastrointestinal diagnosis listed above.

Horizon BCBSNJ shall deny 88305 for any services greater than four (4) units and the diagnosis is not listed above.

No additional reimbursement will be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

History
01/22/2018: Policy approved

CPT® is a registered trademark of the American Medical Association.

Policy 117_v1.0_01222018