Pathology/Lab Coding Alert

Update your microdissection guidelines, too.

Just when Correct Coding Initiative (CCI) policy and CPT® 2012 finally agree on the block as the special-stain code unit of service, CCI takes back its equivalent policy for immunohistochemistry (IHC) stains.

CMS' new NCCI Policy Manual, effective Jan. 1, 2012, includes this and several other policies that will impact coding and reimbursement for your lab. Read on to make sure you're up to speed on the following changes that could affect your bottom line.

Contrast 'Specimen' and 'Block'

CPT® definitions make it clear that you should bill one unit of the following codes for each distinct IHC antibody stain:

• 88342 -- Immunohistochemistry (including tissue immunoperoxidase), each antibody
• 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.

But the formal descriptors don't tell the entire story -- one unit for "each antibody" isn't all you need to consider. "Longstanding AMA advice is that the full unit of service prescription for 88342 and 88360-88361 may be described as 'each uniquely identified (reported) antibody per each different specimen,'" says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc. and publisher of the Pathology Service Coding Handbook, in The Villages, Fla.

Medicare adopted this definition until the Oct. 1, 2009 NCCI Policy Manual update, when it departed from the AMA by focusing on the surgical pathology block instead of specimen.

"In a surprising reversal of a policy that has been in effect since Oct. 2009, Medicare is going back to the specimen as the unit of service for IHC codes 88342, 88360 and 88361 instead of the block," Padget says.

Although the NCCI Policy Manual maintains instruction to report special stain codes 88312-88313 (Special stain, including interpretation and report ...) per block, it removes 88342, 88360 and 88361 from that guidance, providing instead the following new directive for the IHC codes:

"If a single immunohistochemical stain (procedure) for one or more antibodies is performed on multiple blocks from a surgical specimen, multiple slides from a cytologic specimen, or multiple slides from a hematologic specimen, only one unit of service may be reported for each separate specimen."

That directive could cost you money. "It's not unusual for pathologists to examine IHC stains on multiple tissue blocks from a single specimen," says R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark. For instance, you can expect your pay to be cut in half for a specimen that's processed in two blocks, starting Jan. 1.

Example: The pathologist examines a sentinel lymph node biopsy for a breast cancer patient. He processes the node in two blocks, with three pancytokeratin-stained slides from each of three levels within each block for a total of 18 slides. Prior to Jan. 1 you would bill the special stain as 88342 x 2 for the two blocks, but after that date, you'll need to bill only one unit of 88342 for the single specimen. That's a pay cut of $105.52 (2012 physician fee schedule national amount, conversion factor 34.0376).

Never per slide: Even though the preceding example involves 18 slides and you could legitimately bill one unit of 88342 for a specimen exam involving a single IHC-stained slide, "you should never code special stains per slide," emphasizes Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

Notice 'Cocktail' Difference

Another way you stand to lose IHC stain pay involves Medicare's new policy for multiple-antibody stains.

Prior to Jan. 1, an IHC stain comprised of multiple antibodies warranted multiple units of service as long as you documented that each antibody provided distinct diagnostic information. Not anymore. The latest NCCI Policy Manual states:

"Physicians should not report more than one unit of service per specimen for an immunohistochemical antibody(s) stain (procedure) even if it contains multiple separately interpretable antibodies."

In other words, "IHC 'cocktail' stains such as PIN4 must now be billed as one unit (one stain) even though multiple antibodies will be individually reported," Padget says.

Old way: A prostate triple stain (PIN4) contains three antibodies -- p504S, which stains adenocarcinoma cytoplasm red; P63, which stains basal cell nuclei brown in prostatic intraepithelial neoplasia (PIN); and CK903, which stains basal cells in benign and PIN specimens. With documentation of the diagnostic contribution of each stain, bill 88342 x 3.

New way: For the same stain and documentation, you can bill only 88342 for a Medicare beneficiary. That would cost your lab $211.04 in lost revenue (2012 physician fee schedule national amount, conversion factor 34.0376)

Look ahead: Medicare's new IHC stain directive presents several challenges to pathologists and coders due to the large menu of single, multiplex, and cocktail antibody stains on the market today. Watch the future issues of Pathology/Lab Coding Alert for updates on this new policy and techniques to achieve compliance.

Include 'Control' in Microdissection Prep

The NCCI Policy Manual update also confirms appropriate billing for the following codes:

• 88380 -- Microdissection (i.e., sample preparation of microscopically identified target); laser capture
• 88381 -- ... manual.

Sometimes molecular-test tissue samples require microdissection as a preparatory step, and these procedures involve preparing microscopically-identified target tumor cells, together with normal tissue used for comparison.

"Consistent with longstanding conventional wisdom, the new NCCI Policy Manual confirms that you should not report 88380-88381 once for the sample containing the tumor and again for the normal tissue sample," Padget says.

Here's why: Codes 88380-88381 include the normal tissue prep because "comparison to 'normal tissue' is a necessary component of the test since an interpretation of the tumor tissue cannot be rendered without it," according to the policy manual.

That's not all: The Jan. 1, 2012 NCCI Policy Manual updates coding policy for other lab and pathology services, such as prostate saturation biopsy, lipoprotein testing, and transfusion medicine codes. Look to future issues of Pathology/Lab Coding Alert to see how these policies will impact your lab.