Key facts for G0416
- Medicare payment
- $356.72
- PFS non-facility, national
- Coverage code
- C
- carrier judgment, so the Medicare contractor decides coverage
- Practitioner MUE
- 1
- MAI 2
- NCCI PTP pairs
- 16
- 16 hospital outpatient
- LCDs and articles
- 0 / 0
TL;DR
G0416 is a Level II code from the G section (procedures and professional services, temporary), in use since 2009: "Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method". Under the 2026 physician fee schedule (October release) G0416 carries 3.51 work, 7.06 practice-expense and 0.11 malpractice RVUs, which at $33.4009 per RVU pays $356.72 non-facility and no facility amount facility before the locality adjustment. Qualifying APM participants get $358.50 at $33.5675. Its 2026 Q4 MUEs per date of service: practitioner 1 (MAI 2, Code Descriptor / CPT Instruction); hospital outpatient 1 (MAI 2, Code Descriptor / CPT Instruction). In the NCCI PTP files v323r0 G0416 appears in 3 practitioner pairs as column 2 and 13 as column 1 (most often with 17311, 17313, 87172), and in 3 hospital outpatient pairs as column 2 and 13 as column 1. No current LCD or billing article lists G0416; its HCPCS coverage code is C (carrier judgment, so the Medicare contractor decides coverage). HCPCS record: BETOS T1G (lab tests - other (Medicare fee schedule)); pricing indicator 13; type of service 5 (diagnostic laboratory). Nearby codes: G0413, G0420, G0411, G0410.
G0416 descriptor and code status
The October 2026 HCPCS Level II file describes G0416 as “Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method”. It sits in the G section (procedures and professional services, temporary), listed with the other G codes. Although searches often call it the "G0416 CPT code", G0416 is a HCPCS Level II code maintained by CMS, not an AMA CPT code; both go in the same procedure-code field on the claim.
| Field | Value |
|---|---|
| Short descriptor | Prostate biopsy, any mthd |
| Added to HCPCS | 2009-01-01 |
| Last action | N (no maintenance), effective 2015-01-01 |
| Coverage code | C: carrier judgment, so the Medicare contractor decides coverage |
| Pricing indicator | 13: physician fee schedule, priced by the contractor |
| BETOS category | T1G: lab tests - other (Medicare fee schedule) |
| Type of service | 5: diagnostic laboratory |
Medicare payment for G0416
Under the 2026 physician fee schedule (October release) G0416 carries 3.51 work, 7.06 practice-expense and 0.11 malpractice RVUs, which at $33.4009 per RVU pays $356.72 non-facility and no facility amount facility before the locality adjustment. Qualifying APM participants get $358.50 at $33.5675. The amounts below are national figures from the October 2026 CMS files; the contractor applies the locality, rural or state adjustment and the beneficiary's cost sharing.
Physician fee schedule (RVU26D)
Status A: active: paid separately under the physician fee schedule when covered. Global period XXX (global surgery concept does not apply); PC/TC indicator 1 (diagnostic test with professional (26) and technical (TC) components).
| Component | Non-facility | Facility |
|---|---|---|
| Work RVU | 3.51 | 3.51 |
| Practice expense RVU | 7.06 | NA |
| Malpractice RVU | 0.11 | 0.11 |
| Total RVUs | 10.68 | NA |
| National payment (CF $33.4009) | $356.72 | n/a |
| Qualifying APM participant (CF $33.5675) | $358.50 | n/a |
- Multiple procedures (modifier 51): no multiple-procedure reduction
- Bilateral (modifier 50): 150% bilateral adjustment does not apply
- Assistant at surgery: assistant at surgery paid only with documentation; co-surgeons: co-surgeons not permitted; team surgery: team surgeons not permitted
- Physician supervision of diagnostic procedures: supervision concept does not apply
G0416 also carries 26 and TC rows in the RVU file, priced separately from the global service.
| Modifier | Status | Non-facility | Facility |
|---|---|---|---|
| 26 | A | $167.34 | $167.34 |
| TC | A | $189.38 | n/a |
Hospital outpatient (OPPS Addendum B)
Status indicator Q2 (T-Packaged codes), APC 5673 (Level 3 Pathology), national unadjusted payment $366.21 with a minimum unadjusted copayment of $73.25.
Medically Unlikely Edits for G0416
Its 2026 Q4 MUEs per date of service: practitioner 1 (MAI 2, Code Descriptor / CPT Instruction); hospital outpatient 1 (MAI 2, Code Descriptor / CPT Instruction). The practitioner MUE is a date-of-service policy edit: units above the limit deny even when split across lines, and appeals rarely succeed.
| Setting | MUE (units/DOS) | MAI | CMS rationale |
|---|---|---|---|
| Practitioner services | 1 | 2 Date of Service Edit: Policy | Code Descriptor / CPT Instruction |
| Facility outpatient hospital | 1 | 2 Date of Service Edit: Policy | Code Descriptor / CPT Instruction |
The MUE lookup for G0416 shows every setting next to any other code on the same claim.
NCCI edits and add-on rules
In the practitioner PTP file v323r0, G0416 is the column-2 (bundled) code in 3 active pairs, 100% of which allow a modifier and the column-1 code in 13 (92% modifier-allowed); 3 earlier pairs have been deleted. CMS's most frequent rationale for the bundled pairs: HCPCS/CPT procedure code definition.
| Column-1 code | Pairs |
|---|---|
| 17311 (CPT; descriptor licensed by AMA) | 1 |
| 17313 (CPT; descriptor licensed by AMA) | 1 |
| 87172 (CPT; descriptor licensed by AMA) | 1 |
| Column-2 code | Pairs |
|---|---|
| 0403U (CPT; descriptor licensed by AMA) | 1 |
| 0424U (CPT; descriptor licensed by AMA) | 1 |
| 0433U (CPT; descriptor licensed by AMA) | 1 |
| 88160 (CPT; descriptor licensed by AMA) | 1 |
| 88161 (CPT; descriptor licensed by AMA) | 1 |
| 88162 (CPT; descriptor licensed by AMA) | 1 |
| 88302 (CPT; descriptor licensed by AMA) | 1 |
| 88304 (CPT; descriptor licensed by AMA) | 1 |
In the hospital outpatient PTP file v323r0, G0416 is the column-2 (bundled) code in 3 active pairs, 100% of which allow a modifier and the column-1 code in 13 (92% modifier-allowed); 3 earlier pairs have been deleted. CMS's most frequent rationale for the bundled pairs: HCPCS/CPT procedure code definition.
| Column-1 code | Pairs |
|---|---|
| 17311 (CPT; descriptor licensed by AMA) | 1 |
| 17313 (CPT; descriptor licensed by AMA) | 1 |
| 87172 (CPT; descriptor licensed by AMA) | 1 |
| Column-2 code | Pairs |
|---|---|
| 0403U (CPT; descriptor licensed by AMA) | 1 |
| 0424U (CPT; descriptor licensed by AMA) | 1 |
| 0433U (CPT; descriptor licensed by AMA) | 1 |
| 88160 (CPT; descriptor licensed by AMA) | 1 |
| 88161 (CPT; descriptor licensed by AMA) | 1 |
| 88162 (CPT; descriptor licensed by AMA) | 1 |
| 88302 (CPT; descriptor licensed by AMA) | 1 |
| 88304 (CPT; descriptor licensed by AMA) | 1 |
G0416 is neither an add-on code nor a designated primary code in the 2026 Q4 NCCI add-on edit file.
Pair counts show exposure, not the answer for one claim. Check G0416 against a second code to see whether the pair bundles and whether a modifier can separate the services.
Medicare coverage policies for G0416
No current LCD or billing and coding article lists G0416. The HCPCS coverage code C means carrier judgment, so the Medicare contractor decides coverage, and any National Coverage Determination for the service still applies.
Denials to expect on G0416
the 26 or TC modifier does not fit the component billed
the claim lacks the description, invoice or pricing detail a contractor-priced code needs
Where QuickIntell fits for G0416 claims
QuickCode supports qualified coder review of units, modifiers and NCCI pairs for G0416 before the claim leaves, and QuickRCM carries claim readiness and the denial follow-up when an edit or coverage policy is missed.
Frequently asked questions: HCPCS G0416
What does HCPCS code G0416 describe?
"Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method" (short descriptor "Prostate biopsy, any mthd"), in the G section (procedures and professional services, temporary). Added 2009-01-01; last action N (no maintenance) effective 2015-01-01.
Is G0416 a CPT code?
No. G0416 is a CMS HCPCS Level II code; CPT codes are the AMA's five-character set. Searches for "G0416 CPT code" mean this Level II code.
What does Medicare pay for G0416?
Under the 2026 physician fee schedule (October release) G0416 carries 3.51 work, 7.06 practice-expense and 0.11 malpractice RVUs, which at $33.4009 per RVU pays $356.72 non-facility and no facility amount facility before the locality adjustment. Qualifying APM participants get $358.50 at $33.5675.
How many units of G0416 can be billed per day?
Its 2026 Q4 MUEs per date of service: practitioner 1 (MAI 2, Code Descriptor / CPT Instruction); hospital outpatient 1 (MAI 2, Code Descriptor / CPT Instruction). For the practitioner MUE (MAI 2), units above 1 deny for the whole day as a policy limit; denials arrive as CARC 151.
Does Medicare cover G0416?
No current LCD or billing article lists G0416; its HCPCS coverage code is C (carrier judgment, so the Medicare contractor decides coverage).
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.
- HCPCS Level II alpha-numeric file, October 2026Version October 2026 · effective 2026-10-01 · file HCPC2026_OCT_ANWEB_09232026.txtSHA-256 c25240c63108756d…
- Medicare PFS national relative value file RVU26D (non-QPP), October 2026Version RVU26D, released 2026-08-26 · effective 2026-10-01 · file PPRRVU2026_Oct_nonQPP.csvSHA-256 4d0d3f19bd954ffc…
- Medicare PFS national relative value file RVU26D (qualifying APM participants), October 2026Version RVU26D, released 2026-08-26 · effective 2026-10-01 · file PPRRVU2026_Oct_QPP.csvSHA-256 59d3734704853936…
- OPPS Addendum B, October 2026Version October 2026 · effective 2026-10-01 · file 508-compliant-version-2026_October_Web_Addendum_B.09.28.26.csvSHA-256 6ad7393a318bf1b9…
- Integrated Outpatient Code Editor v27.3 data tables: status and payment indicatorsVersion I/OCE v27.3 (October 2026) · effective 2026-10-01 · file Data_Status_Indicator.txtSHA-256 78f119ef0a435351…
- NCCI MUE table, practitioner services, effective 2026-10-01Version 2026 Q4 · effective 2026-10-01 · file MCR_MUE_PractitionerServices_Eff_10-01-2026.csvSHA-256 ef038efaf902b7bd…
- NCCI MUE table, facility services, effective 2026-10-01Version 2026 Q4 · effective 2026-10-01 · file MCR_MUE_OutpatientHospitalServices_Eff_10-01-2026.csvSHA-256 3af9f4e99cc587e2…
- NCCI MUE table, dme services, effective 2026-10-01Version 2026 Q4 · effective 2026-10-01 · file MCR_MUE_DMESupplierServices_Eff_10-01-2026.csvSHA-256 6fa4fbba852f7b74…
- NCCI PTP edits, practitioner, v323r0 (four files)Version v323r0 (2026 Q4) · effective 2026-10-01 · file ccipra-v323r0-f1.TXTSHA-256 7793c0b6686c1e22…
- NCCI PTP edits, hospital outpatient, v323r0 (four files)Version v323r0 (2026 Q4) · effective 2026-10-01 · file ccioph-v323r0-f1.txtSHA-256 063f41b91ef9faa2…
Disclaimer
This page is an operational reference compiled from CMS publications: the HCPCS Level II file, the physician, DMEPOS and clinical laboratory fee schedules, OPPS and ASC addenda, NCCI MUE, PTP and add-on edit tables and the Medicare Coverage Database. Amounts are Medicare national figures before locality and state adjustment; Medicaid and commercial payers set their own. CPT codes are shown as numbers only; CPT descriptors are copyright AMA. Nothing here is legal, clinical or billing advice.
Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.