Summary & Overview
HCPCS G0417: Prostate Needle Biopsy Pathology, 21-40 Specimens
HCPCS Level II code G0417 denotes surgical pathology services encompassing both gross and microscopic examination of prostate needle biopsy specimens when 21–40 cores or specimens are submitted. This code captures a common, resource-intensive pathology service tied to prostate cancer diagnostic pathways and has national relevance due to the volume of prostate biopsies performed and the clinical importance of accurate histopathologic assessment. Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
Readers will find a concise overview of the code’s clinical scope and typical site of service, plus benchmarking context including utilization and reimbursement patterns across major payers. The publication covers coding and billing considerations specific to multi-specimen prostate biopsies, typical documentation elements that support medical necessity, and comparisons of how the service is covered by major commercial insurers and Medicare. It also summarizes implications for laboratory workflow and coding compliance. Data not available in the input will be noted where applicable.
Billing Code Overview
HCPCS Level II code G0417 describes surgical pathology, gross and microscopic examination, for prostate needle biopsy, any method, 21-40 specimens. This service involves the comprehensive pathological evaluation of prostate tissue obtained via needle biopsy, including gross assessment and microscopic interpretation of multiple specimens.
-
Service type: Surgical pathology (gross and microscopic examination)
-
Typical site of service: Pathology laboratory or hospital anatomic pathology department
Clinical & Coding Specifications
Clinical Context
A 67-year-old male with an elevated prostate-specific antigen (PSA) and an abnormal digital rectal exam is referred for transrectal ultrasound-guided prostate needle biopsy. The urologist obtains 24 core needle biopsy specimens during the same session to sample bilateral peripheral and transition zones. Specimens are placed in separate containers and sent to the hospital histology laboratory. The pathology team performs gross examination, embedding, and microscopic evaluation to assess for adenocarcinoma, Gleason grading, perineural invasion, and other histologic features. The pathology report documents the number of positive cores, tumor extent per core, Gleason score, and any ancillary testing performed. Billing uses HCPCS Level II code G0417 for surgical pathology gross and microscopic examination of prostate needle biopsy specimens when the specimen count is between 21 and 40. Typical site of service is an outpatient hospital pathology laboratory or hospital outpatient clinic supporting a urology procedural suite. Common billing modifiers include 26 for the professional component and TC for the technical component when split billing between the pathologist and the facility.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|