Effective Date: October 14, 2019

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

Scope:
Products included:

• NJ FamilyCare/Medicaid Plan
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• CPT Code 88305: Level IV - Surgical pathology, gross and microscopic examination. These examinations would be ordered as a gross and microscopic pathology exam or a gross and microscopic tissue exam.

Policy:
CPT code 88305 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 NJ Health 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 CPT code 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 CPT code 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 reimbursement for all other diagnoses not listed above for the same patient on the same date of service.

Procedure:
Horizon NJ Health shall deny CPT code 88305 for any services greater than twelve (12) units and including a prostate diagnosis listed above.

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

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

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

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:

Centers for Medicare and Medicaid Services (CMS). Medically Unlikely Edits cms.gov/NationalCorrectCodInitEd/08_MUE.asp