Pathology/Lab Coding Alert

Don't report flow cytometry with immunology, cytopathology

If you want to code 2005's new flow cytometry and morphometric analysis codes with confidence, you'll need to know how to maneuver edit pairs in the latest National Correct Coding Initiative edits (version 11.0). NCCI 11.0 took effect Jan. 1. You can access the edits online at www.cms.hhs.gov/physicians/cciedits/default.asp.
 
CPT Codes 2005 deleted flow cytometry code 88180 and replaced it with five new codes:

  88184 -    Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker

+88185 - ... each additional marker (list separately in addition to code for first marker)

  88187 -    Flow cytometry, interpretation; 2 to 8 markers

  88188 - ... 9 to 15 markers

  88189 - ... 16 or more markers.

Now NCCI restricts how you can use these codes. Because CPT also added three new cell-count immunologycodes that you previously reported using a flow-cytometry code, NCCI 11.0 clarifies coding for these services. "You should not report both immunology and flow cytometry codes for a single procedure," says William Dettwyler, MT-AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore.
 
Don't miss: NCCI 11.0 bundles flow cytometry codes 88182-88184 and 88187-88189 with quantitative immunology codes. The NCCI Policy Manual states, "Quantitative cell counts performed by flow cytometry (codes 86064 [B cells, total count], 86359-86361 [T cells; ...], 86379 [Natural killer (NK) cells, total count], and 86587 [Stem cells (i.e., CD34), total count]) should not be reported with the flow cytometry interpretation CPT codes 88187-88189 since there is no interpretative service for these quantitative cell counts."

Watch for: NCCI 11.0 also adds edit pairs to clarify that for a single specimen, you shouldn't report flow cytometry codes with the following nongynecology cytopathology codes:

88108 - Cytopathology, concentration technique, smears and interpretation (e.g., Saccomanno technique)

88112 - Cytopathology, selective cellular enhancement technique with interpretation (e.g., liquid-based slide preparation method), except cervical or vaginal

88160 - Cytopathology, smears, any other source; screening and interpretation

88161 - ... preparation, screening and interpretation

88162 - extended study involving over 5 slides and/or multiple stains.

Although pathologists might perform both cytopathology - to examine cell morphology - and flow cytometry - to study cellular surface-marker antigens - this NCCI edit prohibits billing both services together.
"Even if the pathologist performs two distinct procedures, you should not override the edit with modifier -59 (Distinct procedural service) if you only have one specimen," Dettwyler says.

Hidden trap: In the past, NCCI edits bundled IHC (88342) with flow cytometry (88180) - even if the lab performed the two tests on different, but similar, specimens such as bone marrow aspirate and bone marrow biopsy. Now the same bundling prohibition moves forward because NCCI 11.0 pairs the new flow cytometry codes 88184-88189 with 88342.

CMS bundled these codes because the agency claimed that pathologists could typically establish a diagnosis using either method alone. But CMS says that you can override the edit pairs, in some cases. "The provider may report both CPT codes if both methods are required because the initial method is nondiagnostic or does not explain all the light microscope findings," according to the NCCI Policy Manual. "To report both 88342 and flow cytometry codes together, you have to document the need for both methods, and use modifier -59," Dettwyler says.

ISH Codes Don't Mix and Match

With new codes to report manual and automated morphometric analysis of in situ hybridization (ISH), NCCI 11.0 added edit pairs to ensure that you use these codes properly:

88365 - In situ hybridization (e.g., FISH), each probe

88367 - Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), each probe; using computer-assisted technology

88368 - ... manual.

NCCI says you can't report together the manual  and automated versions of an ISH morphometric analysis - the lab performs one test or the other - so the 88367/88368 code pair is mutually exclusive. Also, quantitative ISH includes any qualitative evaluation, according to NCCI, which pairs 88367 and 88368 with 88365.

Nor should you use a separate code for the morphometric analysis of an ISH
specimen - new codes 88367 and 88368 include the morphometric analysis. That's why you should not report 88358 (Morphometric analysis; tumor) in addition to 88367 or 88368. "These edit pairs complete NCCI's logic, which bundled 88365 with 88358 in previous versions," Dettwyler says.

Experts warn: Don't use codes that describe the laboratory steps for ISH or FISH (88271-88275, Molecular cytogenetics ...), which Medicare pays on the Clinical Lab Fee Schedule, in addition to the 88365-88367 codes for the same test. "Codes from either one group or the other properly describes a given ISH procedure," Dettwyler says. See "Classify ISH Test as an Adjunct Service" on page 19 of this issue of Pathology Lab Coding Alert for a complete discussion of these codes.

Choose 1 Code for IHC

With CPT 2005's revised coding for immunohistochemistry, you'll have to ensure that you select the single code that best describes an IHC service from the following possibilities:

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.

As with ISH, NCCI bundles IHC morphometric analysis by manual (88360) versus automated (88361) methods as a mutually exclusive code pair - the lab  performs either computer-assisted or manual analysis of the slides.
 
Similarly, because the quantitative IHC tests (88360 and 88361) include the qualitative analysis, NCCI adds an edit pair for new code 88360 with 88342. Labs typically analyze IHC-stained slides against positive and negative controls - a qualitative analysis - before proceeding to a quantitative analysis on appropriate areas of the specimen. "The qualitative IHC analysis is the first step in a quantitative examination, so NCCI bundles code 88342 as a component of 88360," says Laurie Castillo, CPC, CPC-H, CCS-P, owner of Castillo Consulting in Manassas, Va.

Avoid Consultation Codes in Addition to Interpretation

Many pathology procedures include the physician interpretation and report, and you shouldn't additionally bill a consultation code for those services. That's why NCCI 11.0 bundles clinical pathology consultation codes 80500 (Clinical pathology consultation; limited, without review of patient's history and medical records) and 80502 (... comprehensive, for a complex diagnostic problem, with review of patient's history and medical records) with new codes for morphometric analysis (88367, 88368), cell counts (86064, 86379, 86587) and bone marrow aspiration (G0364).

NCCI also bundles codes for "second opinion" consultations on a referred case (88321-88325) with several new pathology codes that the referring pathologist may have used as an adjunct to his original diagnosis. The NCCI Policy manual states, "Providers should not report other pathology CPT codes such as .... 88342, 88180, etc., for interpretation of stains, slides or material previously interpreted by another pathologist."

Warning: That's why you shouldn't report together 88321-88325 with new codes 88184-88189 (flow cytometry), 88360 (manual IHC morphometric analysis), and 88367-88368 (ISH morphometric analysis). "If the referring pathologist has performed an adjunct evaluation of the specimen, the consulting pathologist should not report the same procedure again in addition to the consultation," Castillo says. But if the consulting pathologist performs an adjunct procedure such as flow cytometry on tissue submitted for a consultation (88323, Consultation and report on referred material requiring preparation of slides), you can report both services together using modifier -59.