Pathology/Lab Coding Alert

Surgical/cytology service versus clinical cytogenetics distinguishes codes

With two sets of codes that describe in situ hybridization (ISH), you have to know when to use each group. Changes in CPT Codes 2005 clarify that you should now use 88365 for adjunct ISH tests for surgical or cytopathology cases, not only for tissue specimens.

Before CPT 2005 removed the word "tissue" from 88365 (In situ hybridization [e.g., FISH], each probe), experts recommended that you report 88365 for tissue specimens - like a breast biopsy for Her-2/neu - and report molecular cytogenetics codes (88271, Molecular cytogenetics; DNA probe, each [e.g., FISH], through 88275) for nontissue ISH - like urine cytology, for recurring bladder cancer.

But removing "tissue" from the 88365 definition leaves us scrambling for a new dividing line. "The context of the study - not the specimen - separates the two code series today. You should distinguish the two sets of codes based on whether the ISH test is an adjunct to a surgical or cytopathology case, versus part of a clinical, chromosomal analysis," says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., a pathology business publishing company in Simpsonville, Ky.

ISH With Surgical/CytoPathology Cases

Use codes 88365, 88367 (Morphometric analysis, in situ hybridization [quantitative or semi-quantitative], each probe; using computer-assisted technology) and 88368 ( ... manual) for surgical and cytopathology adjunct testing.

"The tests detect nonchromosomal specific DNA and RNA sequences using fluorescent, enzyme or other labels on DNA or RNA ISH probes," says Donald Cohen, MD, former member of the College of American Pathologists (CAP) Economic Affairs Committee and pathologist with Sharon Regional Health System in Sharon, Pa.

The 88365-88368 ISH tests help the pathologist visualize and localize a wide variety of cellular constituents including infectious agents (such as HPV, EBV), or define clonality in B-lymphocytes, Cohen says.

Pathologists also use ISH to define cell proliferation rates (such as histone H3) or to localize hormones in specific tissue cells (such as proinsulin), Cohen says. "All of these methods maintain essential cellular and tissue morphologic details for correlation and diagnosis, manually or by computer-assisted technology," he says.

Don't miss: CMS and CAP published instructions for 88365-88368 that support using these codes for pathologist tissue and cellular ISH services. "[Codes] 88365-88368 are intended to be used when performed as an ancillary analysis to surgical pathology and cytopathology services," according to the December 2004 CAP Today.
 
Similarly, CMS advocates using codes 88365-88368 for ISH services "when performed by a physician" (NCCI Policy Manual, version 10.3, available on the Internet at www.cms.hhs.gov/physicians/cciedits/chap10.pdf). "Although the instruction wording leaves much to be desired for clarity, both CMS and the CAP seem to agree that you should report 88365-88368 for tissue and cytology ISH performed by a surgical pathologist or a cytopathologist," Padget says.

Report 88271-88275 for Clinical Cytogenetics ISH

CPT's cytogenetics section also includes codes that describe ISH tests - 88271-88275 (Molecular cytogenetics ...) and 88291 (Cytogenetics and molecular cytogenetics, interpretation and report) - so you should know when to report these codes instead of 88365-88368.

Reality: "Use the molecular cytogenetics codes for primary or adjunctive molecular cytogenetics studies," Cohen says. "The studies represent fluorescent, enzyme or other labels on ISH DNA probes that hybridize with specific sequences in or on interphase cell nuclei or metaphase chromosomes following cell culture and spread preparation." Medical professionals use these tests to detect specific genes (including amplification or translocation), or oncogenes, or to identify chromosomes and chromosome aneuploidy, Cohen says.

CAP also points toward 88271-88275 for cytogenetics ISH tests. "When in situ hybridization is done as an ancillary analysis to cytogenetic studies, codes in the cytogenetic range (88271-88275) should be assigned," according to the December 2004 CAP Today.

CMS' NCCI Policy Manual gives this instruction: "When in situ hybridization is performed ... by a nonphysician, it should be reported using appropriate CPT codes in the range 88271-88275."

"Medicare is saying it should never get an 88365-88368 technical charge (such as 88365-TC) by itself - there has to be a professional service for somebody to bill these codes," Padget says. If the ISH procedure doesn't include physician interpretation, use the 88271-88275 codes instead of the 88365-TC-88368-TC codes, he says.

Don't let the CMS statement confuse you - although 88271-88275 don't have a professional component on Medicare's Physician Fee Schedule, you can use 88291 to report a pathologist's interpretation of these tests. "In choosing the proper code for ISH studies, the context drives the code selection," Padget says. "Use 88365-88368 for a study that's ancillary to a surgical or cytology case; these always involve a pathologist interpretation. 

"Use 88271-88275 for a study that's conducted in a clinical, chromosomal analysis context. If a physician's interpretation is medically necessary, add code 88291 for the professional component of the study," he says