Pathology/Lab Coding Alert

Capture $38.05 with this new-opportunity code.

When your pathologist examines and selects previously diagnosed tissue for molecular analysis, you didn't have a code to capture the service -- until now.

For the first time, CPT 2011 gives you the ability to get paid for this service by adding 88363 (Examination and selection of retrieved archival [i.e., previously diagnosed] tissue[s] for molecular analysis [e.g., KRAS mutational analysis]). Your practice could recover $38.05 for the procedure, based on the Medicare physician fee schedule national facility total amount using conversion factor 33.9764.

Follow these tips to learn when and how to code for this service.

Tip 1: Pathologist Must Select Material

Simply retrieving an archive case report, blocks, and/or slides from storage isn't enough to warrant an 88363 charge.

To use the code, the pathologist must identify and select "appropriate tumor tissue from previous surgical specimen," according to CPT Changes 2011 -- An Insider's View. "This identification and selection is critically needed for the successof subsequent ... gene mutation analysis."

In other words, "the pathologist must exercise medical judgment in selecting archival tissue for subsequent molecular analysis before you can report 88363," says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc. and publisher of the Pathology Service Coding Handbook, in The Villages, Fla.

The pathologist will also typically review the initial report and initiate any necessary block or slide preparation of the chosen tissue to move forward for molecular testing.

Send out -- or not: You can use 88363 whether an in-house molecular lab or an outside reference laboratory will perform the molecular analysis. If you perform the test in house, beware of potential conflict with microdissection codes, as you'll see in "88380 and 88363: Don't Double Dip for Microdissection" later in this issue.

Tip 2: KRAS is Example Test

You can use 88363 when your pathologist selects archive tissue for "molecular analysis," which includes a wide range of testing. By listing KRAS using "e.g." in parenthesis, CPT indicates that selection for KRAS is only an example -- selection for other tests might warrant the code as well.

Define 'molecular analysis': "Certainly any molecular test that's appropriately described by codes in the 83890-83914 range (Molecular diagnostics) would qualify for application of 88363 when warranted by the circumstances," Padget says.

Although you may be able to use 88363 to describe archive specimen tissue selection for tests such as molecular cytogenetics (88271-88275, Molecular cytogenetics ...) and in situ hybridization (such as 88365, In situ hybridization [e.g., FISH], each probe), CPT does not provide specific direction on the matter.

Watch units: "Presumably you should report 88363 for each archive specimen examination/selection episode, regardless of the number of molecular tests that follow," Padget says.

Tip 3: Use 88363 for 'Signed Out' Cases

The use of "archival" in the code definition has generated some confusion for coders.

"Because the code references 'archival' tissue(s), we've wondered if we're restricted to using the codes for cases that have been signed out a specific number of days," says Ana C. Garcia, biller/coder for Scripps Health in San Diego.

Days don't matter: The number of days between the original case and the 88363 service is not the key factor in determining if it's appropriate to use 88363. Don't confuse CPT's use of the term "archival tissue(s)" with Medicare's definition of an "archived specimen" associated with date of service determination-- the two terms are not the same.

For purposes of CPT code 88363, the case is "archival" when the pathologist has released the case report and sent the slides/tissues to be stored. That means you should not use 88363 if the pathologist or treating physician decides to prep tissue for a molecular test such as KRAS before the pathologist completes the primary case and signs it out.

Tip 4: Avoid Modifiers TC/26

Although 88363 involves a technical and professional component, you shouldn't report the code with modifiers TC (Technical component) and 26 (Professional component).

Here's why: The Medicare physician fee schedule doesn't allow modifiers TC and 26, but provides a higher payment rate for non-facility (non-hospital patient) versus facility (hospital patient). The payment difference represents the technical component of the service, such as sectioning blocks selected by the pathologist for molecular testing. Similarly, the Medicare outpatient prospective payment APC fee schedule lists a payment rate for 88363, which accounts for the technical work the hospital provides for the service for an outpatient.

When an independent lab supports the pathologist's work and reports 88363 with place of service 11 (Medical office) or 81(Independent lab) on its Form CMS-1500 claim, the lab will receive the higher non-facility payment.

"A hospital that's due payment for the technical support of the pathologist's 88363 work will be paid via the outpatient prospective payment system APC fee schedule upon filing Form CMS-1450 (UB-04) with its Part A contractor," Padget says.