Pathology/Lab Coding Alert

Professional and technical billing impact your bottom line

You have five code choices for estrogen receptor (ER) and progesterone receptor (PR) tests -- but do you know where to look for payment and compliance information to ensure you're getting all the pay you deserve?

Refer to "4 Steps Ensure That You Clear Every ER/PR Coding Hurdle" in Pathology/Lab Coding Alert Vol. 11 no. 9 for a refresher on choosing the proper code. Read on to learn how Medicare fee schedule and component billing will influence your ER/PR pay.

Zero In on Clinical Lab

If you're billing Medicare for one of the ER/PR assays, you'll look to the Clinical Laboratory Fee Schedule (CLFS) for pricing information. Here's the pay you can expect for the following codes based on the CLFS national limit amount:

• 84233 (Receptor assay; estrogen) ($92.26)
• 84234 (... progesterone) ($92.92)

Medicare pays these on the CLFS because they're clinical laboratory tests. As such, they do not have a technical and professional component.

"You would not expect a pathologist to interpret these tests except under unusual circumstances," says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc. and publisher of the Pathology Service Coding Handbook, in The Villages, Fla.

Immunohistochemistry Needs Physician Service

Unlike 84233 and 84234, ER/PR immunohistochemistry testing requires the pathologist's input, and Medicare pays for the service on the Physician fee schedule. Compare the following national facility totals for each global (combined technical and professional) service based on conversion factor 36.8729:

• 88342 -- Immunohistochemistry (including immunoperoxidase), each antibody ($100.29)
• 88360 -- Morphometric analysis, tumor immunohistochemistry (e.g., Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, each antibody; manual ($120.21)
• 88361 -- ... using computer-assisted technology ($147.12) "Immunohistochemistry markers always require a pathologist's interpretation, and you designate that portion of the work by appending modifier 26 (Professional component) if you're not entitled to bill the global charge," Padget says.

For instance: "We might manually evaluate quantitative ER/PR IHC stains for breast specimens," says R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark. If you're billing only for the pathologist's evaluation, you should code this case as 88360-26 x 2.

Another example: "Sometimes we prepare and evaluate myeloperoxidase stains on bone marrow aspiration specimens for leukemia patients," Stainton says. Because a single entity performs both the technical and professional component in this example, you should report 88342.

Watch for technical modifier: If you're billing only for the lab's technical work in preparing the immunohistochemistry slides, not for the pathologist's interpretation, you should report the appropriate CPT code with modifier TC (Technical component).