Medicare AdvantageBilling CodesHigh impact
MA00.058, Reimbursement of Surgical Pathology Services for Prostate Biopsy
Independence Blue Cross·Pathology, Urology, Oncology·Claims & Billing
Effective date
Mar 2, 2026
We identified it
Jun 19, 2026
Summary
Independence Blue Cross Medicare Advantage establishes a new policy requiring surgical pathology for prostate biopsies to be billed exclusively with HCPCS code G0416 (one unit of service for multiple biopsies from the same patient on the same date), and explicitly prohibits reimbursement when CPT code 88305 is used. Billing teams must immediately update billing systems and provider education to enforce this coding requirement.
Action Required
By March 2, 2026: Billing team must (1) Update billing software to deny or reject claims for surgical pathology of prostate biopsies (related to procedure codes 55705-55715) when submitted with CPT 88305 and force use of HCPCS G0416 instead; (2) Configure system to enforce one unit of service for G0416 regardless of number of prostate biopsies obtained on the same date from the same patient; (3) Audit existing pending and recently processed claims for prostate biopsy pathology to identify any submitted with CPT 88305 and resubmit with G0416; (4) Communicate to all providers, pathology services, and hospital outpatient facilities that G0416 with 1 unit is the ONLY acceptable code for prostate biopsy surgical pathology on both CMS-1500/837p (professional) and UB-04/837i (facility) claims; (5) Ensure medical necessity documentation is available in records for all prostate biopsy pathology claims. Failure to use G0416 will result in claim denials.