Pathology/Lab Coding Alert

Automation distinction is the key

You can stop pulling out your hair over how to report manual versus computer-assisted morphometric analysis using immunohistochemistry (IHC) or in situ hybridization (ISH). CPT Codes 2005 adds and revises several codes in the 88360s, largely to distinguish manual from automated IHC and ISH studies.

The code changes clear up other questions too - like whether to report the  ISH per probe, and how to overcome National Correct Coding Initiative (NCCI) edits that had stopped your lab from capturing some qualitative and quantitative IHC and ISH services.

Just follow our experts' examples of the "new way" and the "old way" to see how CPT 2005 will solve your morphometric analysis coding problems.

Distinguish ISH Quantification/Automation With 3 Code Options

By changing an existing code and adding two new codes, CPT 2005 gives you three options for reporting ISH.

Paralleling the change for IHC coding (see "IHC Coding Basics: Know Method for CPT 2005" on page 92), the 2005 code update distinguishes between qualitative and quantitative tests and between manual and automated methods. The new and revised codes are:

 88365 - In situ hybridization (e.g., FISH), each probe (Do not report 88365 in conjunction with 88367 or 88368 for the same probe)

 88367 - Morphometric analysis, in situ hybridization (quantitative or semiquantitative) each probe; using computer-assisted technology

 88368 - ... manual.

"The note following revised code 88365 confirms that it's to be used only with qualitative ISH tests, while two separate new codes now describe today's more common quantitative tests," says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., a pathology business publishing company in Simpsonville, Ky.

Example: You should report fluorescence ISH (FISH) breast-tissue Her-2/neu tests that use morphometric analysis to quantify gene overexpression as 88367 or 88368, depending on whether the pathologist counts the slide manually or using computer-assisted technology. "Don't report 88365 in addition to 88367 or 88368 for these tests," says Laura Edgeworth, HTL, CPC, coding and audit specialist with Pathology Service Associates LLC (PSA), in Florence, S.C.

'Each Probe' Solves ISH Unit-of-Service Mystery

What is the unit of service for ISH tests? You should report the analysis per DNA probe, according to CPT 2005.

Before the latest code updates, the answer to the unit-of-service question was not so clear. "Experts and the AMA used to advise that 88365 included multiple probes, but the use of 'each probe' in the CPT 2005 definition clarifies that this is no longer the case," Padget says. Codes 88365, 88367 and 88368 all include the words "each probe" in the definitions.

Don't miss: Clarifying the unit of service for ISH tests could be significant to reimbursement. "Including 'each probe' in the code definition represents a major step toward correct valuation if these ISH services," says Paul R. Landauer, director of health policy and payment at Abbott Molecular Diagnostics in Abbott Park, Ill. 

NCCI Edit Problem? No Problem

The 2005 code updates also solve an NCCI bundling problem that left coders wondering how to report ISH with morphometric analysis.

Prior to NCCI version 10.0 (implemented January 2004), coders reported 88365 with 88358 for tissue ISH plus tumor morphometric analysis for Medicare beneficiaries. Although the College of American Pathologists (CAP) protested the NCCI 10.0 edit pair, CMS claimed that 88365 included both a qualitative and quantitative assessment, so coders could no longer report two codes to Medicare.

Providing two new codes (88367, 88368) for morphometric analysis of ISH tests resolves this dilemma. You no longer need two codes to report morphometric analysis of ISH tests. "The two new codes stand alone for ISH morphometric analysis by quantitative method, and you report the code based on whether the pathologist uses manual or computer-assisted quantification methods," Padget says. "It's now clear that there's not a separately reportable qualitative element."

Practice Your 2005 ISH Coding Skills

Try your hand at this coding example to see if you understand how to use the new codes compared to how you used the old codes.

The procedure: The lab performs a Her-2/neu FISH assay on a formalin-fixed, paraffin-embedded breast tumor tissue specimen. The procedure uses DNA probes, which are small segments of fluorescent DNA material. In a process called "hybridization," one probe that fluoresces green attaches specifically to chromosome 17 (where the Her-2 gene resides), and another that fluoresces orange attaches specifically to the Her-2 gene itself. Using a fluorescence microscope and computer-assisted image analysis, the pathologist quantifies the ratio of chromosome-17 fluorescence and Her-2 gene fluorescence to see if the ratio is 1:1 (normal), or if there is an increase in Her-2 gene fluorescence, which would indicate gene amplification.

New way: "Code 88367 best describes the service, because this FISH example uses computer-assisted morphometric analysis," Padget says. Because the test involves two DNA probes, you should report two units of 88367 for this Her-2/neu FISH analysis.

Old way: Prior to CPT 2005, you would have reported this service as 88365 (2004 definition: Tissue in situ hybridization, interpretation and report). Prior to an NCCI 10.0 edit that bundled the two codes, you would have reported the service as 88365, along with 88358 (Morphometric analysis; tumor [e.g., DNA ploidy]) to describe the quantification of the FISH test using morphometric analysis.