Pathology/Lab Coding Alert

Question: Is new code 88363 for a technical or professional service?

Answer: Code 88363 (Examination and selection of retrieved archival [i.e., previously diagnosed] tissue[s] for molecular analysis [e.g., KRAS mutational analysis]) describes both a technical and a professional service.

CPT 2011 introduces 88363 "to accurately report the pathologist's identification and selection of appropriate tumor tissue from previous surgical specimen..." according to CPT Changes 2011: An Insider's View -- clearly describing a professional service. The document goes on to state that the pathologist's tissue identification and selection are critical to the success of the molecular diagnostics test that is to follow.

Look to fees: The Medicare Physician Fee Schedule does not allow technical component (TC) or professional component (26) modifiers with the 88363. However, it does provide a higher payment rate for non-facility versus facility -- and that difference comprises the technical component of the service, such as sectioning blocks selected by the pathologist for molecular testing. Similarly, the Medicare outpatient prospective payment APC fee schedule lists a payment rate for 88363, which accounts for the technical work the facility provides for the service for an outpatient.

Do this: An independent lab (place of service 81) will receive the non-facility (higher) rate to garner pay for the technical component of 88363. A hospital can capture the technical component of the work via the APC payment for 88363.