Pathology/Lab Coding Alert

Hit the payday jackpot for technical component.

The proposed 2019 Medicare Physician Fee Schedule (MPFS) could increase your pay by up to 174 percent for morphometric tumor immunohistochemistry (IHC). But to get that prize, you need to avoid common mistakes and code your cases right – every time.

We’ve got four steps that will help you master reporting your quantitative and semi-quantitative IHC cases using the following two codes:

• 88360 (Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; manual)
• 88361 (… using computer-assisted technology).

Step 1: Choose 1 Code

Whether you report 88360 or 88361 for a case hinges on answering one question: did a human or a microprocessor do the counting (or other visual estimation) of percent IHC-antibody-stained cells?

“The key distinction between 88360 and 88361 is whether the enumeration and evaluation is manual or computer-assisted,” says Peggy Slagle, CPC, coding and compliance manager for the department of pathology/microbiology at the University of Nebraska Medical Center in Omaha.

Do this: If you have a human evaluator using a microscope or computer/digital image to quantify and evaluate stained cells, you should report 88360. On the other hand, if your lab uses an automated image analyzer that provides a quantified result for stained cells, you should report 88361.

Codes 88360 and 88361 describe “morphometric analysis,” which denotes something measured or quantified (or at least semi-quantified). That means the human or the microprocessor will actually “count” some of the stained cells, or at least give a visual approximation of the percentage of stained cells, and report a numeric value as the result.

Avoid: If the result is simply “positive” or “negative” for an IHC antibody stain, or even if it’s a “score” that indicates only characteristics such as stain intensity, you should reject the 88360 family and turn instead toward the qualitative IHC code family starting with 88342 (Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure).

Compliance alert: CMS’s NCCI Policy Manual states, “Immunohistochemistry reported with qualitative grading such as 1+ to 4+ shall be reported as CPT^® codes 88342, +88341, and 88344.” If you have IHC results that look something like that, you should consult your payers to see if you can use 88360 or 88361 with appropriate documentation that your lab procedure is not qualitative, but involves enumerating IHC-stained cells.

Step 2: Master the Unit of Service

The 88360-88361 code definitions clearly state the unit of service: “per specimen, each single antibody stain procedure.” Let’s break that down to see how you should report these codes.

Per specimen: Whether you quantify IHC staining on multiple slides and/or multiple tissue blocks, you should report just one unit of 88360 or 88361 for a single specimen. The NCCI Policy Manual states that if a single IHC procedure “is performed on multiple blocks from a surgical specimen, multiple slides from a cytologic specimen, or multiple slides from a hematologic specimen, only one unit of service shall be reported for each separate specimen.”

Per procedure: Don’t let the words, “each single antibody stain…” confuse you. All of those are descriptors for the word, “procedure.” The procedure involves all the steps: from applying the stain, to counting the stained cells, to giving a quantitative or semiquantitative report.

Think you can report multiple units for multiple antibodies in a single stain procedure? Think again. CPT^® instruction states, “Morphometric analysis of a multiplex antibody stain should be reported with one unit of 88360 or 88361, per specimen.” The NCCI Policy Manual puts it this way: “Physicians shall not report more than one unit of service for CPT^® codes 88360 or 88361 per specimen for an immunohistochemical multiplex antibody stain procedure even if it contains multiple separately interpretable antibodies.”

Opportunity: “If your lab preforms two distinct procedures involving separate antibodies on a single specimen, you can separately report each antibody,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark.

Step 3: Focus on Antibodies

The 88360 and 88361 code descriptors list three IHC antibodies: Her-2/neu, estrogen receptor (ER), and progesterone receptor (PR).

Tip: Those are just examples — that’s why the code definition states, “e.g.,” which means “for example.” Your lab might perform morphometric analysis for a host of other IHC stains, like CD117 (c-Kit) for gastrointestinal stromal tumors, MART1 for skin tumors, Ki-67 for breast tumors, or CD138 for plasma cells in leukemia, to name a few examples.

Notice from the last example that the stains aren’t limited to solid tumors, even though the definition states, “tumor histochemistry.” In fact, you should report 88360 or 88361 for any medically-necessary quantitative or semi-quantitative IHC test that your lab performs.

Step 4: Don’t Forget the Modifier

If you’re billing for an independent lab that performs both the technical work (such as preparing and staining the slides) and the professional work (such as evaluating/enumerating the stained slides and reporting results), you should report 88360 or 88361 for the service. These are “global” codes, meaning that the stand-alone code represents both the technical and professional components of the procedure.

On the other hand: If you’re billing for an entity that performs just the technical work, you should report 88360 or 88361 with modifier TC (Technical component). If you’re coding for a pathologist who performs just the professional work, you should list 88360 or 88361 with modifier 26 (Professional component).

Why it matters: Medicare and other payers have a separate payment schedule for the technical and professional components of these procedures. Using the proper modifier, or no modifier, makes all the difference in getting paid the right amount, and avoiding fraudulent claims.

Surprise ending: At the top of the article, we promised a 2019 “payday jackpot” for these codes, and that’s what you’ll get if CMS keeps the payment rates listed in the proposed MPFS for next year. Look at the following table to see what your lab stands to gain for performing these tests next year, depending on which codes and which modifiers you report. Notice that the payment for 88360 technical component does indeed increase by 174 percent!