Pathology/Lab Coding Alert

Question: Should we report flow cytometry phenotyping (88180) per marker, or per study, such as a lymphoma diagnosis that may involve several markers? Is it true that CMS changed the coverage rules for this code so that we can only report it once per study?

New York Subscriber Answer: The descriptor for 88180 (Flow cytometry; each cell surface, cytoplasmic or nuclear marker) clearly indicates reporting the code once for each marker. Although 88180-TC (Technical component) accurately reflects the facility technical work involved in each marker, CMS believes 88180-26 (Professional component) does not reflect contemporary physician practice.
 
In the proposed rule for the 2004 Physician Fee Schedule (Aug. 15, 2003, Federal Register), CMS claims, "There is a single interpretation based on ... all markers tested," not an interpretation "of each marker individually." And, CMS states that paying 88180-26 per marker "may encourage the performance of more markers than may be medically necessary because the pathologist determines what markers to perform."
 
After considering the objections of the College of American Pathologists (CAP) and other individuals and organizations, CMS withdrew its proposal to create a new HCPCS code for flow cytometry phenotyping physician professional services (to be reported per panel or study). Rather, CMS stated in the final rule (Nov. 7, 2003, Federal Register) that it will work in coming months with CAP, the AMA and others "to develop appropriate coding and payment policies for flow cytometry." CMS clearly expects practice guidelines for the number of markers that are medically necessary for at least the common uses of flow cytometry (such as leukemia and lymphoma) to be part of the new code prescription.
 
You should continue to report the technical and professional components of flow cytometry phenotyping studies per marker. Consult your local carriers' medical review policies for specific billing instructions in 2004 (such as a limit on the number of markers that will be paid), and be on the lookout for flow cytometry coding changes in 2005.
 
- Answer provided by Dennis L. Padget, MBA, CPA, FHFMA, president of Padget & Associates, a pathology financial and compliance consulting firm in Simpsonville, Ky.