Wiki 88360

necruz

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We just now started to do the ER/PgR/Her2/Ki67 stains in house. Is it correct to bill 88360 x 4 (for each stain)? Is it also correct to bill the same stains again with the other immunohistochemical stains performed as 88342/88341? Please advise - Thanks
 
It is correct to bill as 88360 if they are reported with quantitative or semiquantitative results. E.g. 'Ki67 labels 40 to 50 % of the tumor cells' If there are no quantitative results, then you will need to bill with 88342/88341.
I'm not sure I understand your second question. You wouldn't bill twice for the same IHC stains but you can bill it with other IHC stains billed with 88342/88341.
 
Thank you rae3613 - The report does have the quantitative results so we will bill 88360 x 4. Let me clarify my 2nd question - the report i am looking at involved only the Left Breast and it had other IHC stains (ex e-cadherin, p40, p63 and a few others) including the ER/PgR/Her2/Ki67 quantitative results. It has been brought up that the ER/PgR/Her2/Ki67 stains can also be billed as IHC stains and therefore we can also bill them as 88342/88341 stains. I disagree and i need clarification. Thanks
 
Oh ok. 88360 is already billing for the IHC stains (with quantitative results). In the CPT under both 88360 and 88342/1 it states ‘Do not report 88342/1/88344 in conjunction with 88360 unless each procedure is for a different antibody.’
You cannot bill both 88360 and 88342 for the same IHC On the same specimen.
 
Hi necruz
I somewhat disagree that the ER/PR/HER2/Ki-67 can also be billed as IHC stains. Please let me explain.
If the ER and PR performed are quantitative (as stated above) - you will bill 88360. (Just so everyone knows the ER and PR can be performed as an IHC and not just quantification).
HER2 and Ki-67 are quantitative both being billed with 88360.
Ki-67 is quantitative even if the number is zero. It will state something like <0 (which is still a quantitative percentage; there however was nothing to find). Bill it 88360.
(HER2 is not IHC) - HER2 can be quantitative (88360); and if the test is "equivocal" a FISH "reflex" may be ordered billing 88377.
The other stains mentioned above - the E-cadherin you will bill with 88342 with XU modifier, p40 bill with 88341 with XU modifier, p63 bill with 88341 with XU modifier, and any other IHC stains performed bill with 88341 with XU modifier. Please make sure your pathologist's is stating why these tests are performed in either the microscopic area or the IHC table to "rule out, rule in, validate xxxxx, confirm xxxxx, etc..." if you are ever faced with a denial. These IHCs are used to differentiate on the kind of cancer the patient may have and any invasions. This is useful information for the treatment plan for the patient - lumpectomy, mastectomy, radiation, chemotherapy (what type/for how long). If we don't know exactly what type of cancer the patient has it becomes difficult to come up with an effective treatment plan for curative care.
Please reach out with any additional questions and have a great evening.
Thank you for listening,
Dana
 
Hi Dana -- You have been a tremendous help. I appreciate your feedback. In regards to the XU modifier, is that for all insurances (Commercial and Medicare) that it can be used on or only Medicare? Thank you.
 
Hi necruz
We follow Medicare guidelines where I work for all payors (commercial, Medicare, or otherwise). If 88360 is billing with 88342 or 88341 we will apply XU modifier to both 88342 and 88341 charges for every patient regardless of their health insurance. The XU modifier is more specific for this scenario.
Have a wonderful evening,
Dana
 
Hi Dana. I'm new to pathology and was wondering if you could help me with a question. We usually bill these 88360 and apply XU to 88342 and 88341 per MUE and NCCI. Now, if the report has an addendum by a different provider and performs 8 more units of IHC (different tests than original ones) on the same block, is it okay to bill 88342.XP and 88341.XP? Should we only bill 88341.XP as corrected claim even though it's a different provider? Any information would help.
 
Hi raphaguz@yahoo.com,
Well, your question has a little bit of a twist - let me try describing the scenarios okay. When was the addendum performed? Was it within the 30 days of acquiring the specimen or after?
I'm going to give another off the top of my head this seriously doesn't exist coding scenarios for this example okay. That 30-day timeline is very important. Please be very cognizant when coding charges from an addendum. There is quite a bit here to provide and I will try to include it all, but please if I have missed something - do not be afraid to question me okay.
First example - breast core biopsy obtained on 08/01/2022 from Dr. Kermit and pathologist performed their interpretation including ER+, PR-, HER2 (equivocal), Ki-67 <80% tumor cells, and also applied a p63 and SMA (smooth muscle actin). We would bill this 88305 (breast core), 88360x4 for the ER, PR, HER2 and Ki-67, along with both 88342 and 88341 (with appropriate modifiers) that was professionally interpretated by J Wayne.
Addendum happens within the 30 days of the initial biopsy received and now 8 additional immunohistochemical stains are applied by a different pathologist for their professional interpretation by Dr Fonzy. In my professional opinion you would bill this as 88341x8 with modifier XP for separate provider. These new stains will still have the same collection date of 8/1/2022 and since you are billing 88341x8 for these new stains doesn't fix anything. Yes, you can bill it out all day long if you would like but your professional charges are going to be denied. Clearly these charges are later than the original ones and are now "solo" without a primary 88342 charge. To sum it up - you are billing 88341x8 without the primary CPT code. I do not know what system you utilize. I can only offer if that this happened in EPIC, I would correct the original invoice and manually add these charges to the existing charges. Do not wait for the denial (I have seen too many cases where "add on charge" was billed without primary charge to change my mind) on this event this evening.
Next scenario that the addendum that was past the 30 days. Are you closely watching your charges? Are you sure that those new 8 immunohistochemical stains are on a BRAND NEW HAR WITH THE CORRECT DOS (Date of service) - the date that the provider ordered that testing to be performed? If not, this is clearly not a coding issue here. You need to reach out to your supervisor for assistance. (If they taught you or gave you a contact for this scenario to contact ~ that is what you use). We are beyond that "30 days" and it has to be all on its own".
I am going to use the original scenario but just update the DOS to 9/10/2022 the date that Dr. Kermit ordered that additional testing to explain the differences here okay. We have a brand new HAR created, and provider Dr. Kermit stated he wanted 8 additional IHC's provided to specimen to rule out, rule in, or otherwise. He is fantastic and will explain why these new 8 additional IHC's are being applied to appeal in his documentation. Pathology department receives the request that is promptly fulfilled. A brand-new addendum dated 9/15/2022 states that due to additional IHC studies requested by Dr. Kermit that (AGAIN I am so very fictious here again) CAM 5.2, CD3, CD5, Kappa, Lambda, TTF-1, CD3, CD4 was applied for professional interpretation by (Dr. Cookie Monster). This is billed with 88342x1 with 88341x7 on the same invoice. I am not telling anyone to quantity bill or line-item bill (that is your facilities preference). I am merely telling you that this is the information your healthcare facility is faced with now.
Again, I apologize if I missed anything and please everyone reach out here. There is a lot of information and I want to be sure nothing fell through the cracks.
Have a wondaful evening,
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB, RHIT
 
Hi, this discussion forum is helpful, explaining a lot regarding 88360. Wondering about, we can still use 88360 for use of Ki-67 if the specimen is not of Breast but of GI location.
 
Hello aamipatel,
Yes, you may. I apologize for my delay. I believe I have information that may assist you for proper CPT coding assignment.
Again, yes, 88360 may be clearly used for other areas of the body. I see it in other areas including brain specimens.

Oh goodness, maybe it is time I address the immunohistochemical stains. Qualitative versus Quantitative here today.
I am clearly not here to push someone into attending my pathology presentation, but this is something that I do cover in my pathology presentation(s).
Just having the opportunity for me to speak out loud with my knowledge versus typing words in this post is completely night and day here.

Let me provide the basics a pathology coder needs to know on the difference between Qualitative (88342) and Quantitative (88360). There are other CPT code variations of course but let's stick with the basics from our CPT book for my examples okay.

First let me discuss Qualitative immunohistochemical stains:
A pathologist applies an immunohistochemical stain and reviews it (with appropriate controls) and is able to determine if the result is positive or negative. That is an 88342 charge.
Qualitative can be a positive result, negative result or just noncontributory due to several different reasons.

Fictious Examples to share:
Immunohistochemical stain for Helicobacter (H Pylori) is positive. This is billable
ALK1 immunohistochemical stain is negative. This is billable
Immunohistochemical stain for EMA is positive. This is billable
TTF-1 immunohistochemical stain is positive. This is billable
CDX-2 immunohistochemical stain is noncontributory. Not billable

Next let's review quantitative immunohistochemical stains:
A pathologist applies an immunohistochemical stain and reviews it and quantifies the tumor cells. Please do not be confused on this. If the pathologist’s is counting tumor cells this is totally appropriate, but if they are quantifying other things that is clearly NOT NEOPLASTIC related; this is not your coding route.

Let’s review the CPT book on what 88360 states “Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure, manual”.
The pathologist actually counts the tumor cells identified and provides it in a percentage or a number.

Again, more Fictious Examples to share:
Ki-67 proliferation index is <4%. This is billable
Estrogen Receptor at <10%. This is billable
Progesterone Receptor <75%. This is billable
PD-L1 with <1% no PDL expression. This is billable
HER2 is equivocal. This is billable

Again, let me reiterate that you need to be super careful reviewing the pathology report. Was the immunohistochemical stain positive or negative? Or not billable due to being noncontributory.
Next, the quantification of an immunohistochemical stain for tumor. Were tumor cells actually counted? Do you have the proof to support billing CPT 88360 (or CPT code) due to my simple discussion.
When in doubt; I need you to please query, ask your pathologist’s what was being evaluated and why. Some of the pathologist’s I have met in my pathology career have been such great teachers and have explained things in such simple manner. The pathologist(s) I have met in my career have been so kind. They love discussing pathology. Please do not be afraid to ask a question. You know asking a question and communicating is a two way street. You ask something and they share but if they are faced with a "whopper" ~ they in return will possibly ask for your guidance on some coding assistance.

You have a case that you are clearly unsure about after my advice on the differences between qualitative and quantitative you email at nerdypathologycoders@gmail.com and send me information (no PHI) to review to assist you okay.

Have a fantastic evening,
Dana
 
Hello and Good Evening sdaniels;
You brought up a very great immunohistochemical coding point today.
May I break it down in the terms that I code?
There are two primary immunohistochemical stains (those that are qualitative and those that are quantitative) "clearly" among others here. The focus this evening is on just these two scenarios okay.
88342 is primary procedure with 88341 the add on - those are qualitative. The pathologist applied an immunohistochemical stain and it is either "positive or negative".
I am reviewing your example - positive for Mammoglobin, AE1/AE3, ER, PR and are negative for HER2. There is only positive and negative discussed here. It is 88342/88341. No one has quantified anything.

No worries let's review 88360 (I look at my CPT book all the time that the majority of my pathology pages have been ripped out). Let us review 88360. It states in our CPT book that it is "morphometric analysis, tumor immunohistochemistry (eg, Her2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen each single antibody stain procedure, manual. It has to be presented quantitative; a numerical number like a percentage or value or otherwise (a quantitative number has to be provided). If someone (pathologist's) states that it is "low" that is not sufficient to bill 88360 CPT assignment here. Again; quantification is the rule of thumb. If you are billing 88342 with 88360 you are probably appealing it all; may want to be sure you have it documented to receive the entitled reimbursement (RVUS).
I hope this helps shed light on your coding woes, please reach out if you need additional assistance.
Dana
 
Hello and Good Evening sdaniels;
You brought up a very great immunohistochemical coding point today.
May I break it down in the terms that I code?
There are two primary immunohistochemical stains (those that are qualitative and those that are quantitative) "clearly" among others here. The focus this evening is on just these two scenarios okay.
88342 is primary procedure with 88341 the add on - those are qualitative. The pathologist applied an immunohistochemical stain and it is either "positive or negative".
I am reviewing your example - positive for Mammoglobin, AE1/AE3, ER, PR and are negative for HER2. There is only positive and negative discussed here. It is 88342/88341. No one has quantified anything.

No worries let's review 88360 (I look at my CPT book all the time that the majority of my pathology pages have been ripped out). Let us review 88360. It states in our CPT book that it is "morphometric analysis, tumor immunohistochemistry (eg, Her2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen each single antibody stain procedure, manual. It has to be presented quantitative; a numerical number like a percentage or value or otherwise (a quantitative number has to be provided). If someone (pathologist's) states that it is "low" that is not sufficient to bill 88360 CPT assignment here. Again; quantification is the rule of thumb. If you are billing 88342 with 88360 you are probably appealing it all; may want to be sure you have it documented to receive the entitled reimbursement (RVUS).
I hope this helps shed light on your coding woes, please reach out if you need additional assistance.
Dana
Thank you so much Dana. That's what I thought. If there isn't a percentage or a value, then 88360 is not appropriate. I'm struggling in this area. Can you look at the codes below and verify which set is correct for the above scenario? There is a discrepancy between what I coded and what another person coded: (88305 X 2, 88342 X 2, 88341 X 8) vs (88305 X 2, 88342 X 2, 88341 X 6, 88360 X 2 )or (88305 X 2, 88342 X 2, 88360 X 6)?
 
Hello sdaniels,
Again, I will try to assist you. From the final interpretation without seeing the gross or microscopic I cannot clearly tell the difference between 88305 or 88307. I'd like to pretend it is a punch skin biopsy, but I really do not know reviewing the information provided. The gross and microscopic (with no PHI would assist). The reason(s) why I state this is because ~ let's review specimen A & B together with this information.
Were these skin biopsies, or breast lesions with margins reviewed?
A) states within the final interpretation that "patient's history of breast carcinoma, extending to peripheral margin"
B) states within the final interpretation that "patient's history of breast carcinoma, extending to peripheral & deep margins"

Next let's discuss the immunohistochemical stains:
Specimen A:
Mammoglobin, AE1/AE3, ER, PR, HER2 were either positive or negative (no quantification provided)
Specimen B:
Mammoglobin, AE1/AE3, ER, PR, HER2 were either positive or negative (no quantification provided)

Coding stains can be horribly cumbersome sometimes, so I'll walk you through this.
Specimen A: You bill 88342x1 for the Mammogloblin, 88341x4 (for the AE1/AE3, ER, PR, HER2)
Specimen B: You bill 88342x1 for the Mammogloblin, 88341x4 (for the AE1/AE3, ER, PR, HER2)

Let me summarize:
If this was a skin for example punch biopsy from two different sites we would bill at the end of the day
88305x2
88342x2
88341x8

If this was deemed a breast lesion with margins reviewed (not shared so unsure here???)
88307x2
88342x2
88341x8

Again, let me reiterate what I know. If the immunohistochemical stain is postive or negative (it is a qualitative stain). The first charge is billed with 88342 with subsequent charges billed with 88341.

If someone felt that 88360 (from your example above) was warranted to be billed it CLEARLY should have been displayed within the pathology report in a quantitative state (%, numerical, or otherwise here).
There is absolutely no way to support 88360 with a positive or negative finding unless you have THAT NECESSARY QUANTIFICATION. (If it was the pathologist's questioning ~do not be shy, many are so incredibly kind, just explain that you need a quantitative state to capture RVU's for getting CPT 88360 if you possibly felt they missed that opportunity.
Most do not know. Our pathologist's work super hard, and long. If I recall correctly from one of my pathologist mentors during their 8 years of training, they get that one "class in school". It clearly in my logistics isn't enough. It is a constant open communication line here from me. Since 2012 to now I still appreciate the opportunity to discuss new pathology trends
I am going to give a shout out to all those billers that appeal these scenarios. This is again the stuff that keeps me up at night and absolutely applaud every single one of you!!
The CCI edits are flooding appeals FOR ALL PAYORS because 88342, 88341 doesn't play well with 88360. Some billers have been there for so long and have taken the authority to "just" write stuff off if it is small enough and no one cares. I had so many denials that 88342 was denied because of 88360 so they wrote off the 88342 (small dollar amount I am guessing??) and now I had to deal with the other copious amounts of 88341 charges that were denied. I can provide fictious examples of this of course.
I apologize for being lengthy,
Please reach out to me if you have any questions.
Or PM me, if necessary, okay
Dana
 
Hello sdaniels,
Again, I will try to assist you. From the final interpretation without seeing the gross or microscopic I cannot clearly tell the difference between 88305 or 88307. I'd like to pretend it is a punch skin biopsy, but I really do not know reviewing the information provided. The gross and microscopic (with no PHI would assist). The reason(s) why I state this is because ~ let's review specimen A & B together with this information.
Were these skin biopsies, or breast lesions with margins reviewed?
A) states within the final interpretation that "patient's history of breast carcinoma, extending to peripheral margin"
B) states within the final interpretation that "patient's history of breast carcinoma, extending to peripheral & deep margins"

Next let's discuss the immunohistochemical stains:
Specimen A:
Mammoglobin, AE1/AE3, ER, PR, HER2 were either positive or negative (no quantification provided)
Specimen B:
Mammoglobin, AE1/AE3, ER, PR, HER2 were either positive or negative (no quantification provided)

Coding stains can be horribly cumbersome sometimes, so I'll walk you through this.
Specimen A: You bill 88342x1 for the Mammogloblin, 88341x4 (for the AE1/AE3, ER, PR, HER2)
Specimen B: You bill 88342x1 for the Mammogloblin, 88341x4 (for the AE1/AE3, ER, PR, HER2)

Let me summarize:
If this was a skin for example punch biopsy from two different sites we would bill at the end of the day
88305x2
88342x2
88341x8

If this was deemed a breast lesion with margins reviewed (not shared so unsure here???)
88307x2
88342x2
88341x8

Again, let me reiterate what I know. If the immunohistochemical stain is postive or negative (it is a qualitative stain). The first charge is billed with 88342 with subsequent charges billed with 88341.

If someone felt that 88360 (from your example above) was warranted to be billed it CLEARLY should have been displayed within the pathology report in a quantitative state (%, numerical, or otherwise here).
There is absolutely no way to support 88360 with a positive or negative finding unless you have THAT NECESSARY QUANTIFICATION. (If it was the pathologist's questioning ~do not be shy, many are so incredibly kind, just explain that you need a quantitative state to capture RVU's for getting CPT 88360 if you possibly felt they missed that opportunity.
Most do not know. Our pathologist's work super hard, and long. If I recall correctly from one of my pathologist mentors during their 8 years of training, they get that one "class in school". It clearly in my logistics isn't enough. It is a constant open communication line here from me. Since 2012 to now I still appreciate the opportunity to discuss new pathology trends
I am going to give a shout out to all those billers that appeal these scenarios. This is again the stuff that keeps me up at night and absolutely applaud every single one of you!!
The CCI edits are flooding appeals FOR ALL PAYORS because 88342, 88341 doesn't play well with 88360. Some billers have been there for so long and have taken the authority to "just" write stuff off if it is small enough and no one cares. I had so many denials that 88342 was denied because of 88360 so they wrote off the 88342 (small dollar amount I am guessing??) and now I had to deal with the other copious amounts of 88341 charges that were denied. I can provide fictious examples of this of course.
I apologize for being lengthy,
Please reach out to me if you have any questions.
Or PM me, if necessary, okay
Dana
Hi Dana, I can't thank you enough for your help with this one. I was right! I hope it's okay if I contact you in the future, should I have any other difficult cases. Thank you! I appreciate your thorough explanation!
Thanks again, Stacey
 
Hi Dana, I can't thank you enough for your help with this one. I was right! I hope it's okay if I contact you in the future, should I have any other difficult cases. Thank you! I appreciate your thorough explanation!
Thanks again, Stacey
You are very welcome, Stacey ~
I am super pleased that I was able to assist. If you ever need anything, please feel free to reach out.
Have a fantastic evening!
Dana
 
Hello sdaniels
No, there is nothing from your post that has additional immunohistochemical stains. Your post only discusses SOX-10 with PRAME warranting 88342x1, 88341x1.
Goodness: that may be a great question to pose to your pathologists though. The reason I simply state that is because I have pathologist's that use "melanoma markers" that contain "Melan-A, HMB-45, with SOX-10" and by chance what if one was in error omitted here? Pathologists are super busy. Be the radar. From my review it was two stains 88342 with 88341x1 but what if something was missing, right?
You stated to review the melanoma profile; there is nothing there to even bill an immunohistochemical stain. It was all within their final interpretation.
Every pathologist's documents differently. That is not a coders problem. That is a facility problem not having auto fill or smart text's or auto fill in information readily available to make things uniform. Uniform isn't a new concept here. I'm all about RVUs for my pathologist's but tell me where you want me to focus my coding attention to. You state melanoma profile; that doesn't contain one stain. Not ideal for RVU's here.
I'm hopeful I provided some feedback here.
Not exactly had planned but I'm not one to sugar coat something when something seems amiss here.
Dana
 
Hello sdaniels
No, there is nothing from your post that has additional immunohistochemical stains. Your post only discusses SOX-10 with PRAME warranting 88342x1, 88341x1.
Goodness: that may be a great question to pose to your pathologists though. The reason I simply state that is because I have pathologist's that use "melanoma markers" that contain "Melan-A, HMB-45, with SOX-10" and by chance what if one was in error omitted here? Pathologists are super busy. Be the radar. From my review it was two stains 88342 with 88341x1 but what if something was missing, right?
You stated to review the melanoma profile; there is nothing there to even bill an immunohistochemical stain. It was all within their final interpretation.
Every pathologist's documents differently. That is not a coders problem. That is a facility problem not having auto fill or smart text's or auto fill in information readily available to make things uniform. Uniform isn't a new concept here. I'm all about RVUs for my pathologist's but tell me where you want me to focus my coding attention to. You state melanoma profile; that doesn't contain one stain. Not ideal for RVU's here.
I'm hopeful I provided some feedback here.
Not exactly had planned but I'm not one to sugar coat something when something seems amiss here.
Dana
Thank you so much! I agree! Merry Christmas and Happy New Year!
 
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