Summary & Overview
HCPCS G0416: Prostate Needle Biopsy Surgical Pathology
HCPCS Level II code G0416 denotes surgical pathology services for prostate needle biopsy specimens, encompassing both gross and microscopic examinations. This code is used when pathologists process and interpret prostate tissue obtained via needle biopsy to determine histologic diagnoses such as benign prostatic tissue, prostatic intraepithelial neoplasia, or carcinoma. Nationally, accurate coding of prostate biopsy pathology is important for clinical documentation, quality measurement, and payment integrity across laboratory and hospital settings.
Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the code’s clinical context, typical sites of service, and the common billing modifiers associated with pathology services. The publication also covers benchmark considerations and policy-relevant topics affecting lab and hospital billing for surgical pathology, such as appropriate use of pathology-specific procedure codes and implications for claim adjudication.
This summary equips clinicians, coders, and revenue cycle professionals with a clear understanding of what G0416 represents, where it is performed, and the kinds of documentation and claim elements commonly associated with prostate needle biopsy pathology services. Data not available in the input is noted where applicable in detailed sections.
Billing Code Overview
HCPCS Level II code G0416 describes surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method. This service involves the pathological evaluation of prostate tissue obtained through needle biopsy, including both macroscopic (gross) assessment and microscopic review to identify benign or malignant findings.
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Service type: Surgical pathology procedure involving histopathologic examination
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Typical site of service: Pathology laboratory or hospital outpatient pathology department
Clinical & Coding Specifications
Clinical Context
A 66-year-old male with rising prostate-specific antigen (PSA) and a suspicious lesion on multiparametric prostate MRI undergoes transrectal ultrasound-guided prostate needle biopsy. The urologist obtains multiple core needle samples from targeted and systematic sextant locations; specimens are placed in separate labeled containers and sent to the pathology laboratory for processing. In the histopathology workflow, a surgical pathologist performs gross examination, documents specimen orientation and core lengths, prepares tissue cassettes, performs microscopic evaluation with hematoxylin and eosin stains, and issues a final surgical pathology report describing benign tissue or grading and staging of prostate adenocarcinoma when present. Billing uses HCPCS Level II code G0416 for surgical pathology gross and microscopic examinations of prostate needle biopsy specimens. Typical site of service is an outpatient ambulatory surgery center, hospital outpatient department, or office-based clinic where the biopsy is performed; the pathology work is performed in a clinical laboratory or hospital pathology department.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | When billing only the pathologist�s interpretive (professional) component separated from technical lab costs |