# Modifiers with multiple specimens with multiple IHC stains



## ColqPath (Apr 21, 2014)

Does anyone know if modifier 76 is appropriate to use when billing G0461 when multiple specimens are examined and more than one IHC done on each specimen.  For example, a stomach biopsy and an esophageal biopsy and a duodenal biopsy are submitted and H. Pylori stains done on each specimen in addition to p53 and CD3 stains on each specimen or at least on two of them.
If billing commercial insurance can more than 1 unit 88342 still be billed in addition to 88343 for additional IHC stains for multiple specimens as in the above example?


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## bbooks (Apr 22, 2014)

The only modifiers available for G0461 and G0462 are TC and 26. Also, these codes are only for Medicare.

For commercial insurance, 88342 is still used for each IHC. 88343 is a new code, an add-on code to be used with 88342, and it is only used for cocktail stains.

For Medicare, G0461 is for the first IHC per SPECIMEN, and G0462 are for each subsequent IHC per specimen. For cocktails, you can only charge once for G0461.

For commercial insurance, 88342 is for each IHC per BLOCK.

Here is an article from CAP that gives a couple of examples: http://www.cap.org/apps/cap.portal?...tml&_state=maximized&_pageLabel=cntvwr#Story1

In the example you gave: "a stomach biopsy and an esophageal biopsy and a duodenal biopsy are submitted and H. Pylori stains done on each specimen in addition to p53 and CD3 stains on each specimen or at least on two of them," assuming the p53 and CD3 were done on each of the 3 specimens, the coding for Medicare would be:
88312 X 3, G0461 X 1, G0462 X 5 CORRECTION: G0461 X 3, G0462 X 3
For commercial insurance it would be:
88312 X 3, 88342 X 6

Also, I a separate reply I will post a link to a thread that discussed this.


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## bbooks (Apr 22, 2014)

Here is the thread: https://www.aapc.com/memberarea/forums/showthread.php?t=101402


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## ColqPath (Apr 22, 2014)

*IHC coding confusion*

Thank you for your reply and the links.  I am still a bit confused when more than one specimen is involved. The wording in the CAP article regarding the G codes where the article states - "Each additional stain on the samespecimen is reported with G0462." Further in the article under Vignette#2 it says to use 2 units Go461! That's why I thought a modifier might be appended to reflect first IHC stain on a separate specimen.  My question then is IHC stains billed to Medicare on separately submitted specimens from different anatomical sites are not billed as separate specimens? (I hope you understand what I'm trying to say.)  So, regardless of separate specimens being examined, the IHC stains performed will always be 1 unit G0461 and any additional IHC stains done on any number of specimens would be billed as multiple units under G0462?  Also, for billing commercial insurance I am confused on the usage of 88343 as an add on code and the example you give for billing commercial insurance.  The CPT book states - when multiple antibodies are applied to same slide use one unit 88342 for the first and one unit of 88343 for each additional separately identifiable antibody. So, why didn't you use 88343 in your example?  I appreciate your input and help in clarifying these new codes.  Thank you!


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## bbooks (Apr 22, 2014)

"I am still a bit confused when more than one specimen is involved. The wording in the CAP article regarding the G codes where the article states - "Each additional stain on the samespecimen is reported with G0462." Further in the article under Vignette#2 it says to use 2 units Go461!"

If you finish the entire sentence, it says, "To HCPCS code this service one would use 2 units of G0461; although the unit of service for this code is each antibody per specimen, the above NCCI guidelines limit billing of second or subsequent antibody stains on the same slide. That is, for cocktails (such as the example in Vinette #2), NCCI guidelines do not allow for a second or subsequent antibody stain on the same slide. "Cocktails" are when more than one antibody is performed on a single slide. I wonder if it's the cocktails that is causing your confusion. It is a very confusing topic! 

"My question then is IHC stains billed to Medicare on separately submitted specimens from different anatomical sites are not billed as separate specimens? (I hope you understand what I'm trying to say.)" 

I'm sorry, I don't quite understand this question.

"So, regardless of separate specimens being examined, the IHC stains performed will always be 1 unit G0461 and any additional IHC stains done on any number of specimens would be billed as multiple units under G0462?"

Yes. For Medicare this is correct. Medicare is billed per specimen, per single or multiplex (otherwise known as a "cocktail") antibody stain.  I didn't understand this question clearly until I read it again and realized my error above. The first IHC on each specimen would be coded G0461. Each additional stain (assuming it is not a cocktail) would be coded G0462.

"Also, for billing commercial insurance I am confused on the usage of 88343 as an add on code and the example you give for billing commercial insurance. The CPT book states - when multiple antibodies are applied to same slide use one unit 88342 for the first and one unit of 88343 for each additional separately identifiable antibody. So, why didn't you use 88343 in your example?"

88343 is only used for cocktail stains. Cocktails are when "multiple antibodies are applied to the same slide."  I was assuming that in your case the p53 and the CD3 were not a cocktail, that they were applied to two separate slides. If the p53 and the CD3 were applied to the same slide AND they were separately identifiable, then you would code 88442 and 88343 for each specimen. If the p53 and the CD3 were applied to the same slide but they were NOT separately identifiable, then it would be just 88342.

Also remember that for non-Medicare, 88342 and 88343 are per BLOCK. So, if you had a single antibody applied to 3 blocks of one specimen, you can charge 88342 X 3. If you had a cocktail of 2 antibodies applied to 3 blocks, AND each antibody was separately identifiable, then you could charge 88342 X 3, 8343 X 3.


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## JKAHL1@JHMI.EDU (May 3, 2014)

Your statement about these G codes being "only for Medicare" is incorrect.  We have since learned that United Healthcare & affiliates, as well as, BS Federal, Humana, and Coventry all ALL excepting these G codes.  Additionally, we use (on the profee side) 26 AND 59 modifiers all the time.


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## bbooks (May 5, 2014)

When you refer to the other private insurance accepting the G-codes, are you referring to the Medicare replacement products for these insurances or all of their products? We do use the G-codes for any Medicare replacement products. I'm sorry if I wasn't clear about these being part of the Medicare usage for these codes.

I looked up the NATIONAL CORRECT CODING INITIATIVE POLICY MANUAL FOR MEDICARE SERVICES, Chapter 10, and discovered that, yes, modifier 59 can be used with G0461 and G0462. (see the excerpt below) I'm sorry for the confusion. My billing person was advising me against using -59. To note, we have not been using the -59 modifier when reporting G0461/G0462 with 88360 (we do use -59 on 88342 when reporting with 88360).

Chapter 10
J. Anatomic Pathology (Cytopathology and Surgical Pathology) 
3. Medicare does not pay for duplicate testing. 
Immunocytochemistry (e.g., HCPCS/CPT codes G0461, G0462, 88360, 
88361) and flow cytometry (e.g., CPT codes 88184-88189) should 
not in general be reported for the same or similar specimens. 
The diagnosis should be established using one of these methods. 
The physician may report both CPT codes if both methods are 
required because the initial method does not explain all the 
light microscopic findings. The physician may report both 
methods utilizing modifier 59 and document the need for both 
methods in the medical record. 

If the abnormal cells in two or more specimens are 
morphologically similar and testing on one specimen by one method 
(HCPCS/CPT codes G0461/G0462 or 88184, 88187, 88188, 88189) 
establishes the diagnosis, the same or other method should not be 
reported on the same or similar specimen. Similar specimens 
would include, but are not limited to: 

 (1) blood and bone marrow; 
 (2) bone marrow aspiration and bone marrow biopsy; 
 (3) two separate lymph nodes; or 
 (4) lymph node and other tissue with lymphoid infiltrate. 

4. Quantitative or semi-quantitative immunohistochemistry 
using computer-assisted technology (digital cellular imaging) 
should not be reported as HCPCS codes G0461/G0462 with CPT code 
88358. Prior to January 1, 2004, it should have been reported as 
CPT code 88342. Beginning January 1, 2004, it should be reported 
as CPT code 88361. CPT code 88361 should not be used to report 
any service other than quantitative or semi-quantitative 
immunohistochemistry using computer-assisted technology (digital 
cellular imaging). Digital cellular imaging includes computer 
software analysis of stained microscopic slides. Beginning 
January 1, 2005, quantitative or semi-quantitative 
immunohistochemistry performed by manual techniques should be 
reported as CPT code 88360. Immunohistochemistry reported with 
qualitative grading such as 1+ to 4+ should be reported as HCPCS 
codes G0461 and G0462.


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## ColqPath (May 8, 2014)

*Modifier 76 is accepted by Medicare*

Trial and error has now proven that modifier 76 is accepted by Medicare when billing for more than one IHC stain on separate specimens on the same date of service.  For example, two biopsies submitted on a Medicare patient as gastric and esophageal and H. Pylori stains are performed on both specimens as well as p53 on esophageal specimen only the billing for the professional component of pathology would be:  G0461-26 (first line item billed), G0461-2676 (2nd line item billed) - these two reflecting the H. Pylori stains on two separate biopsies) and then G0462-26 for the p53 (as 2nd IHC stain on one of the specimens).  I hope this is helpful!


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## bbooks (May 9, 2014)

Our Medicare area, J5, indicates that 76 should not be used with a surgical procedure code. Are the G-codes not considered surgical procedure codes? Did you try using 59 modifier or no modifier and got claims rejected? What was your trial and error process?


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## BABS37 (May 9, 2014)

Just an FYI, the approved modifier list for G0461 and G0462 are:

26, 52, 59, 90, 91, 99, AR, CR, ET, GA, GC, GR, GY, GZ, KX, Q5, Q6, QJ, QP & TC. 

***76*** is not an approved modifier for these codes nor is it appropriate. Just because Medicare is allowing these codes to pass through their edit doesn't make it correct coding. More than likely, they will recoup on these charges once _more _established guidelines are reviewed and charges start getting audited. Modifier 76 is intended for surgical and radiology usage only.  


Modifier 91 Fact Sheet
Definition
?      Repeat clinical diagnostic laboratory test
?      In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results.
Appropriate Usage
?      To identify a subsequent medically necessary laboratory test on the same day of the same previous laboratory test
Inappropriate Usage
?      Used for a rerun of a laboratory test to confirm results
?      Due to testing problems for the specimen
?      Due to testing problems of the equipment
?      When another procedure code describes a series test
?      When the procedure code describes a series of test
?      For any reason when a normal one time result is required


Modifier 76 Fact Sheet
Definition
?      Repeat Procedure by the Same Physician; use when it is necessary to report repeat procedures performed on the same day.
Appropriate Usage
?      On procedure codes that cannot be quantity billed
?      Report each service on a separate line, using a quantity of one and append 76 to the subsequent procedures
?      The same physician performs the services
Inappropriate Usage
?      Appending to a surgical procedure code
?      Appending to each line of service
?      Repeat services due to equipment or other technical failure
?      For services repeated for quality control purposes
Additional Information
?      Medicare considers two physicians, in the same group with the same specialty performing services on the same day as the same physician
?      For all procedure codes that cannot be quantity billed, always use a quantity of "1"
?      To avoid denials, bill all services performed on one day on the same claim
?      For repeat clinical diagnostic laboratory tests, use modifier 91 if the service cannot be quantity billed
?      Indicate in the electronic narrative record or Box 19 of the CMS 1500 claim form, the total number of services performed that day


Correct Use Of Modifier 59 With Cytopathology Codes
Often it is not clear whether modifier 59 or modifier 76 should be used with repeat procedures. The Correct Coding Initiative (CCI) Manual provides guidance for the correct usage of modifier 59 with cytopathology CPT codes:
When cytopathology codes are reported, the appropriate CPT code to bill is that which describes, to the highest level of specificity, what services were rendered. Accordingly, for a given specimen, only one code from a group of related codes describing a group of services that could be performed on a specimen with the same end result (e.g., 88104-88112, 88142-88143, 88150-88154, 88164-88167, etc.) is to be reported. If multiple services (i.e., separate specimens from different anatomic sites) are reported, modifier -59 should be used to indicate that different levels of service were provided for different specimens from different anatomic sites. This should be reflected in the cytopathologic reports.

Also refer to Medicare's Processing Manual, Capter 16, Section 100.5.1- this is listed in your ICD-9 book in Appendix G-PUB 100 References as well under clinical laboratory services.

http://www.cms.gov/Regulations-and-...ternet-Only-Manuals-IOMs-Items/CMS018912.html


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## bbooks (May 9, 2014)

I understand the 91 modifier as only for those clinical lab tests paid under the clinical laboratory fee schedule. G0461 and G0462 are under the physician fee schedule.

Has anyone submitted multiple units of G0461 with no modifier (other than TC and 26) and had them denied? For example, 2 specimens each with an IHC?

In the same example, 2 specimens each with an IHC, is anyone using the 59 modifier (in addition to TC and 26) and having it rejected?


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