Pathology/Lab Coding Alert

Recap CCI Policy Manual explanations.

Unlike in some past years, you won’t get off the hook easily with a quiet third quarter Correct Coding Initiative (CCI) update for your lab.

In fact, the July 1, 2014 CCI version 20.2 brings 20,729 new edit pairs. “With only 212 terminations, we see a net gain this quarter of 20,517 new edit pairs for a total of 1,334,994 active edit pairs (or reasons not to pay you for what you do) in the database,” says Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla.

Make sure you’re ready for some key bundles that you’ll find in CCI 20.2 that could impact your pay for certain pathology and laboratory services. 

Choose One Immunohistochemistry Code

You’ve been using two new “G” codes for qualitative immunohistochemistry (IHC) stains for Medicare beneficiaries since Jan. 1, but this quarter you’ll face new CCI edits involving the codes. 

In fact, you’ll find 22 new edit pairs with the following two codes in the column 

2 position:

• G0461 — Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain
• G0462 — ... each additional single or multiplex antibody stain (list separately in addition to code for primary procedure).

Specifically, CCI now lists the following three CPT® codes as column 1 codes with the preceding “G” codes:

• 88342 — Immunohistochemistry or immunocytochemistry, each separately identifiable antibody per block, cytologic preparation, or hematologic smear; first separately identifiable antibody per slide
• 88360 — Morphometric analysis, tumor immunohistochemistry (e.g., Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, each antibody; manual
• 88361 — ... using computer-assisted technology.

Look back: At the first of this year, CMS added G0461 and G0462 to describe qualitative IHC stains for Medicare beneficiaries instead of 88342 and +88343 (…each additional separately identifiable antibody per slide [List separately in addition to code for primary procedure]). You report one or more of these codes when your lab performs an immuno “stain,” which involves applying an antibody that selectively binds to an antigen on cells to create visual changes that the pathologist can use to provide a diagnosis, according to Peggy Slagle, CPC, coding and compliance manager for the department of pathology/microbiology at the University of Nebraska Medical Center in Omaha.

No surprise: With the “G” codes replacing 88342-+88343 for Medicare and with CPT® instruction already restricting the use of 88342 with 88360-88361 (Do not report 88360, 88361 with 88342 unless each procedure is for a different antibody), the new CCI edits come as no surprise. But notice that the CPT® instruction opens the door for cases in which you might be able to report multiple IHC codes together.

CCI 20.2 further opens the door by listing these new edit pairs with a modifier indictor of “1.” Generally, a modifier indicator of “1” means that if you have adequate documentation supporting how the procedures are separate, such as a separate anatomic site or different session, you may be able to submit both codes, according to Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CPCO, owner of MJH Consulting in Denver, Co. 

But the CPT® note also indicates that you can report the codes together if the lab performs distinct tests using different antibodies. That means you might be able to append a modifier (such as 59, Distinct procedural service) to the second code of the pair and report both services.

Watch Medicare’s ‘Duplicate Testing’ Rule

In addition bundling all of the IHC codes with each other, CCI 20.2 also bundles G0461-G0462 with the following codes:

• 86152 — Cell enumeration using immunologic selection and identification in fluid specimen (e.g., circulating tumor cells in blood) 
• 88184-88189 — Flow cytometry ...

A careful reading of Medicare’s NCCI Policy Manual explains these edits:

“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.”

Difference: Unlike most edit pairs that you can override if you perform the procedures on different specimens, that’s not necessarily the case with these codes. The Policy Manual goes on to state, “Similar specimens would include, but are not limited to: 

• blood and bone marrow 
• bone marrow aspiration and bone marrow biopsy 
• two separate lymph nodes 
• lymph node and other tissue with lymphoid infiltrate.

Only chance: According to the policy manual, you can report both IHC and flow cytometry codes together only 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.”

Although CMS made these changes to the Policy Manual effective Jan. 1 of this year, many of the relevant CCI edit pairs did not appear until the latest version 20.2 update.

CTC: Because the circulating tumor cell (CTC, 86152) lab method may involve antibody stains for cytokeratins, CCI 20.2 bundles 86152 with G0461-G0462. The CTC procedure includes any IHC antibody stains that are part of the procedure.  

Bill Only De Novo Stains 

CCI 20.2 also bundles G0461-G0462 with the following codes:

• 88321 — Consultation and report on referred slides prepared elsewhere
• 88323 — Consultation and report on referred material requiring preparation of slides
• 88325 — Consultation, comprehensive, with review of records and specimens, with report on referred material.

The key to these edit pairs also lies in the CCI Policy Manual, as follows:

“When reporting CPT® codes 88321-88325, physicians should not report other pathology HCPCS/CPT® codes such as 88312, 88313, G0461, G0462, 88187, 88188, 88189, etc., for interpretation of stains, slides or other material previously interpreted by another pathologist. HCPCS/CPT® codes 88312, 88313, and G0461/G0462 may be reported with CPT® code 88323 if the physician performs and interprets these stains de novo.”

Bottom line: If your pathologist performs one of these consultation services for material received from an outside lab, you should not bill for an IHC stain if the referring lab performed the stain and their pathologist already interpreted it. Re-evaluating the IHC stain is part of the consultation service.