Wiki 88343

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88343 will be the add on code to 88342 starting in 01/01/2014....we are going to be able to bill per block for these stains now...it is still unknown whether or not medicare is going to accept this...guess thats just gonna be a try it and see when the time comes scenario
 
Quite and uproar about this in our office - and a lot of confusion. Go to page 360 in this document to read Medicare's decision about this. http://www.ofr.gov/OFRUpload/OFRData/2013-28696_PI.pdf

"The CPT Editorial Panel revised the existing immunohistochemistry code, CPT code 88342 and created a new add-on code 88343 for CY 2014. Current coding requirements only allow CPT code 88342 to be billed once per specimen for each antibody, but the revised CPT codes and descriptors would allow the reporting of multiple units for each slide and each block per antibody (88342 for the first antibody and 88343 for subsequent antibodies). We believe that this coding would encourage overutilization by allowing multiple blocks and slides to be billed.
To avoid this incentive, we are creating G0461 (Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain) and G0462 (Immunohistochemistry or immunocytochemistry, per specimen; each additional single or multiplex antibody stain (List separately in addition to code for primary procedure)) to ensure that the services are only reported once for each antibody per specimen. We believe this will result in appropriate values for these services without
creating incentives for overutilization."

Some of our docs are participating in conference call today with CAP to help clarify what this all means.
 
My manager told me that the webinar with CAP yesterday did not really clarify exactly how to use the codes. We are planning to wait a few days with the assumption that Padget will send out an update.
 
Padget did issue an alert yesterday, 12/5. It's quite lengthy and I haven't had a chance yet to examine all of it. I will post something here when I've read through it carefully.
 
Here is a summary of changes from CAP: http://www.cap.org/apps/cap.portal?...index.html&_state=maximized&_pageLabel=cntvwr

I can't post Padget's document here because of copyright. I can summarize parts of his discussion.

As of Jan 1, 2014, 88342 and newly created 88343 will not be valid for Medicare. Medicare has instead created codes G0461 and G0462.

For non-Medicare patients, pending any restrictions from specific payors, we will continue to use 88342 and new code 88343.
88342 Immunohistochemistry or immunocytochemistry, each separately identifiable antibody per block, cytologic preparation, or hematologic smear; first separately identifiable antibody per slide.
88343 (add-on code must be used with 88342) each additional separately identifiable antibody per slide (List separately in addition to code for primary procedure)

Note "per block" as a change from "per specimen." Also note "per slide" in reference to cocktails or multiplex IHC stains (e.g. PIN-4). Thus, for non-Medicare patients, the only time we will use 88343 is with cocktails. Instead of reporting 88342 X 3 for one block of a PIN-4, we will report 88342, 88343 X 2.

The new Medicare codes are:
G0461 Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain)
G0462 Immunohistochemistry or immunocytochemistry, per specimen; each additional single or multiplex antibody stain (List separately in addition to code for primary procedure).

Note "per specimen." Also note that it says "first single" OR multiplex stain. That means the PIN-4 will be coded G0146 X 1.

How we code to Medicare non-multiplex stains will change. For example, ER, PR, Her-2 will now be coded G0461 X 1, G0462 X 2.

Padget also states the reporting per specimen rather than block applies to Medicare, Tricare and Medicaid, but it is not clear to me whether we should use 88342/88343 or the G-codes with Tricare and Medicaid.

Padget also discusses the changes in prostate biopsy coding, summarized here from the CAP web site: "In its decision, CMS established new G codes (G0416-G0419) which will apply to all prostate biopsies (regardless of surgical technique) when 10 or more specimens are reviewed. Increased scrutiny in the reporting of multiple prostate biopsy specimens led to this policy change. Prostate biopsies with fewer than 10 specimens should be billed using CPT code 88305." Note the change: regardless of surgical technique - not just saturation biopsies.
 
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One more thing. For non-Medicare cocktails, if I understand this correctly, 88343 will only be used when the cocktail produces individually identifiable and reportable antibodies, like with the PIN-4. Something like AE1/AE3 would still be one charge of 88342.
 
Who is Padget, and where could I get access to the alert you are summarizing from? We've been trying to figure this out for our dermatopathologists.
 
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I have a question in regards of how to code correct the codes for pathology 88342-88343 for immuno staines, non-medicare patients.
I am confused on how 88343 should be used. The points of view are different.
My understanding is that is that 88343 is to be used for cocktail staines, like PIN 4 for prostate. In my office, other people think it should be used 88342 for first immuno stain that can be billed, after the first one it should be uses 88343.

Exemple 1:
Immunohistochemical studies reveal the tumor is CEA(focal), EMA(focal), BCL2(focal), K903(positive), P63(focal).

I would code this:
88342
88342x4, 59

Others code this
88342
88343x4
What is the correct way ?

Can u please clarify !!!
 
You are correct. 88343 would only be used with cocktail stains. Also note that 88342 can be used PER BLOCK. This was changed when 88343 was introduced.

The new Medicare codes are different. G0461 is used for the first stain and G0462 for each additional stain, single or multiplex. Medicare codes are PER SPECIMEN.
 
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If 88343 is listed as male-only, that is incorrect. Where are you seeing it listed as male only?
 
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I have a billing question about these two new codes for Medicare

bbooks said:
Here is a summary of changes from CAP: http://www.cap.org/apps/cap.portal?...index.html&_state=maximized&_pageLabel=cntvwr

I can't post Padget's document here because of copyright. I can summarize parts of his discussion.

As of Jan 1, 2014, 88342 and newly created 88343 will not be valid for Medicare. Medicare has instead created codes G0461 and G0462.

For non-Medicare patients, pending any restrictions from specific payors, we will continue to use 88342 and new code 88343.
88342 Immunohistochemistry or immunocytochemistry, each separately identifiable antibody per block, cytologic preparation, or hematologic smear; first separately identifiable antibody per slide.
88343 (add-on code must be used with 88342) each additional separately identifiable antibody per slide (List separately in addition to code for primary procedure)

Note "per block" as a change from "per specimen." Also note "per slide" in reference to cocktails or multiplex IHC stains (e.g. PIN-4). Thus, for non-Medicare patients, the only time we will use 88343 is with cocktails. Instead of reporting 88342 X 3 for one block of a PIN-4, we will report 88342, 88343 X 2.

The new Medicare codes are:
G0461 Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain)
G0462 Immunohistochemistry or immunocytochemistry, per specimen; each additional single or multiplex antibody stain (List separately in addition to code for primary procedure).

Note "per specimen." Also note that it says "first single" OR multiplex stain. That means the PIN-4 will be coded G0146 X 1.

How we code to Medicare non-multiplex stains will change. For example, ER, PR, Her-2 will now be coded G0461 X 1, G0462 X 2.

Padget also states the reporting per specimen rather than block applies to Medicare, Tricare and Medicaid, but it is not clear to me whether we should use 88342/88343 or the G-codes with Tricare and Medicaid.

Padget also discusses the changes in prostate biopsy coding, summarized here from the CAP web site: "In its decision, CMS established new G codes (G0416-G0419) which will apply to all prostate biopsies (regardless of surgical technique) when 10 or more specimens are reviewed. Increased scrutiny in the reporting of multiple prostate biopsy specimens led to this policy change. Prostate biopsies with fewer than 10 specimens should be billed using CPT code 88305." Note the change: regardless of surgical technique - not just saturation biopsies.
Click to expand...

I read CR8567 on the NGS website. It says the effective date is 1/1/2014 and the implementation date is 4/7/14. Does this mean we are supposed to be billing these new G codes now? Is the April date the time when Medicare's edits kick in and denial if you use 88342 and 88343? Does anyone have the answer to this? Thanks
 
Someone correct me if I'm wrong, but this document refers to this statement:
This article is based on Change Request (CR) 8567 which informs MACs about changes to HCPCS codes that are new for 2014 and are subject to CLIA edits. The CLIA regulations require a facility to be appropriately certified for each test performed. Make sure your billing staffs are aware of these
changes.​

It looks like this refers to codes that are subject to CLIA edits, not the implementation of the codes themselves.
 
Thank you for your reply. I thought the same but wanted to be sure. One of the physicians I work with thought the code change was delayed.
 
Revised 88342 & 88343 and new G codes

I've read a lot on this forum about this topic. I want to make sure I'm understanding this clearly and can explain it intelligently to a physician. He presented 2 scenarios--
1. Five stains done on 1 block,
2. 5 Blocks from 1 specimen. All the same immuno done on each block (i.e. melan-A, CK, S100)

If the patient has Medicare in #1, it would be coded with G0461 and G0462.
If non- Medicare in #1- it would be coded as 88342x5
If patient has Medicare in #2, it would be coded as G0461 and G0462
If patient non-Medicare in #2, it would be coded as 88342x5

Feedback and any public sources will be appreciated.

Also, I don't think I can get The Pathology Coding Handbook (at least not now) so does anyone have any other suggestions on learning detailed information on pathology coding? I have a strong radiology background and have billed pathology in the past. I am not familiar with a lot of the terminology but am slowly putting it all together. Maybe there is an online course someone can recommend? I did buy Medlearn's Coding Essentials for Laboratories but it doesn't really get into definitions and such. Thanks
 
It is very confusing, isn't it!

1. Five stains done on 1 block,
2. 5 Blocks from 1 specimen. All the same immuno done on each block (i.e. melan-A, CK, S100)

If the patient has Medicare in #1, it would be coded with G0461 and G0462.
If this is 5 different stains, G0461 X 1, G0462 X 4.

If non- Medicare in #1- it would be coded as 88342x5
Correct

If patient has Medicare in #2, it would be coded as G0461 and G0462
G0461 X 1, G0462 X 2. Medicare is per specimen.

If patient non-Medicare in #2, it would be coded as 88342x5
88342 X 15. Non-Medicare is per block. This is a recent change. It used to be per specimen.

Also note that the G-codes apply to Tricare and Medicaid as well as Medicare.

I am fortunate to have Padget's available. I did a quick Google search on pathology coding and came up with this resource that looks quite valuable and I will be exploring further. This site has a link to a discussion of the new 88343 and G-codes.

http://grossing-technology.com/newsite/home/cpt-coding-in-surgical-pathology/
 
Thanks! I think I've got it although a coding manager I work with thinks that in the case of #2 a non Medicare case would be coded as 88342x5 and 88343x2 (for each additional antibody per block) which would mean 88343x10.
Thanks for the link. I plan on asking if my practice will purchase the handbook for me. It appears to be a very valuable resource. Elizabeth
 
88343 is only to be used in combination with 88342 on cocktail stains. In your example, none of the stains were cocktails, so you wouldn't use 88343.

For example, our lab does a Ki-67/Mart-1 cocktail. With this cocktail, there are 2 separately identifiable antibodies on the slide, therefore, we can have two charges: 88342 and 88343.
 
Ahhhh I got it. Now I have to educate this other person so that we code properly.

I truly appreciate all the help you've given me! Thanks.
 
I found a listing of all the stains for various antibodies on a website called NeoGenomics. They give a description of each but don't label them as cocktails! Is there a better source for coders that make it easier to learn and know the stains. Did you learn about the stains from your lab?

Also, with the 88342-- prior to 2014, was each stain coded with a 88342 whether it was a single or multiple (cocktail)?

These new coding changes have actually helped me learn and understand more about the procedures. Thanks
 
Yes, I learned about cocktails from my lab manager. We perform just a handful of them. I was able to explain the difference in coding cocktails to her, and she was able to explain the process to me.

Yes, prior to 2014, before 88343, for non-Medicare cases, cocktails were coded with 88342.
 
modifiers

In the case of the 5 blocks with 3 separate IHC stains done on each, there'd be 15 88342. Are you coding with the 59 modifier after the first procedure? Thanks Elizabeth
 
G0462 Denials from Medicare

Is anyone receiving denials from Medicare? We billed G0461 X 1 and G0462 X 3 and Medicare paid for G0461 but denied G0462 X 3 stating date range not valid with units submitted. Also we tried billing it like below and they denied stating duplicate. They did pay on 1 of the G0462 and denied the other 2 as duplicate. Does anyone know if we need or can add the 59 modifier to the other 2 G0462. Thanks!


G0461 X 1
G0462 X 1
G0462 X 1
G0462 X 1

Thanks,
Sherry
 
I don't do billing, but I haven't heard of any problems from our billing department yet.

The G-codes accept only TC and 26 as modifiers. What were the stains that were done? What dates did you have for the TC and 26 portions of each?
 
We only bill for the professional so we are using 26 modifier and it's for DOS Jan 1 2014 and forward. We get the charges downloaded from the hospital. Thanks!
 
Can you provide all of the details for the case?

Date of service (DOS) for each TC (even though you don't bill for it)
The DOS for the TC portion is the date the specimen was collected.

DOS for each 26.
The DOS for the 26 portion is the date the pathologist rendered a report.

The names of the stains.

The blocks or specimens for each stain.
 
New "G" codes for Pathololgy

I am not sure if any of youi have come across this or not. I was denied payment for the first time with Medicare +Blue for the use of modifer -59 for these codes.G0461 AND B0462. They told me it doesn't really matter how many times they appear on the bill they can not have modifer -59 attached to them. They must be coded with only modifier -26. I so appreciate this forum and how much help you guys have all been. I have learned so much reading what you have posted. Thank you so very much everyone!!
 
We have not been using 59 modifier. I thought we would if we were also doing a flow, but that situation has not come up yet. In one of our most common situations, we would code a non-Medicare case 88360, 88342-59, but with Medicare, we code 88360, G0461 and G0462 with no 59 modifier. We are with WPS Medicare J5.
 
Thenk you for the heads up on all this. I am still learing all this good stuff. I don't know if you have this problem or not but I have trouble getting 88173 getting paid with Medicare. They deny for place of service. I have to argue wiht them them that this is for my professional only and usually they will get paid but then they deny again because I don't have my modifier -26 attached. This is for a professional interp only and should not have mod -26 attached to it. I am so confused anymore! I apprecite your and everyone else's help.
 
Hey, Robyn. If you want to change gears to discuss 88173 you might want to start a new thread with that heading. That way more people will see it an be able to help. :)

If your pathologist did just the professional component of 88173, then, yes, you do need to attach the 26 modifier.
 
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