Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology service (CPT code 88305) provided on August 
30, 2022. 
 
You asked the Plan to pay for the pathology service. You say that this service is supported in the medical 
record. The Plan denied your request. The Plan says the service provided was not coded correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 88305 is Level IV - Surgical pathology, gross and 
microscopic examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis 
Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical 
margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy 
Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy 
Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, 
fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection 
Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy - without uterus Lip, biopsy/wedge 
resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or 
without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary 
tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp, cervical/endometrial Polyp, 
colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, 
paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other 
than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than 
tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy 
Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse 
Vagina, biopsy Vulva/labia, biopsy. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the pathology service. Our reviewer found the documentation 
submitted was reviewed and does not meet criteria. Medicare no longer pays 88305 for prostate needle 
biopsies. G0416 is now the appropriate code for all prostate needle biopsies regardless of the number of 
biopsies/cores. In this case, there is a more appropriate code to report for US guided needle biopsy, prostate. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the pathology service have not been met. Therefore, we decided that the Plan 
does not have to pay for the pathology service (CPT code 88305) provided on August 30, 2022.