Pathology/Lab Coding Alert

Method is the key: Not every HER-2/neu test uses fluorescence in situ hybridization (FISH). If the lab uses a different method, you'll need to report a different code.

Protein Tests Vary

You should report a serum-based HER-2/neu test that does not involve FISH methods using code 83950 (Oncoprotein, HER-2/neu) rather than CPT 88271 (Molecular cytogenetics; DNA probe, each [e.g., FISH]). (For a complete list of CPT codes for FISH and related tests, such as HER-2/neu protein-overexpression assays, see the chart on page 75.) Physicians may order this blood test, which measures serum levels of the HER-2/neu protein, with certain breast cancer treatments.
 
Similarly, you should report a tissue HER-2/neu test that uses a qualitative immunohistochemical (IHC) technique as 88342 (Immunocytochemistry [including tissue immunoperoxidase], each antibody), says Karen Shultz, MT (ASCP), product manager for AmeriPath Oncology, a division of AmeriPath. Because the IHC is not a tissue FISH study for gene amplification, you should not report the service with 88365 (Tissue in situ hybridization, interpretation and report).
 
HER-2/neu IHC testing often requires further analysis and quantification to indicate the patient's suitability for Herceptin therapy. In addition to IHC, labs also often perform morphometric analysis using a system such as ChromaVision ACIS. Code 88358 (Morphometric analysis; tumor) describes the ChromaVision analysis, but a National Correct Coding Initiative (NCCI) edit introduced in April 2003 bundles codes 88342 and 88358. Before the NCCI edit, labs were reporting 88342 for the IHC stain in addition to 88358 for the ChromaVision analysis with a pathologist's interpretation.
 
"The April NCCI update has really confused long-accepted use of 88358 with 88342," says Dennis Padget, MBA, CPA, FHFMA, president of Padget & Associates, a pathology financial and compliance consulting firm in Simpsonville, Ky. "The issue is whether the morphometry is automated or not, based on an April 16 letter from the NCCI medical director suggesting the edit pair is aimed at automated morphometry, not manual morphometry." You might report 88358 with 88342 if the physician performs the cell analysis by manual inspection, but not if a machine does the counting, Padget says. You should watch for a definitive ruling from CMS on this matter.
 
Although NCCI lists a "1" in the modifier column, indicating that you can override the edit pair with modifier -59 (Distinct procedural service), routinely overriding an edit pair is never wise.