Pathology/Lab Coding Alert

Question: When our lab performs ISH procedures, we have PhD scientists who give the results of the test. We've been told that if our physician medical director reviews a certain percentage of cases, that we can use the 88367 instead of 88271 codes. Is that correct, and if so, what is the required percentage of cases?

Tennessee Subscriber

Answer: There is no acceptable percentage of physician (medical director) review that allows you to report in situ hybridization (ISH) performed by a PhD scientist using physician codes.

Based on CMS and AMA direction for using the codes in question, you can report 88365 (In situ hybridization [e.g., FISH], each probe) and 88367-88368 (Morphometric analysis, in situ hybridization [quantitative or semi-quantitative] each probe ...) only if a physician (MD or DO) performs the interpretation. If a FISH test is resulted by a PhD without a pathologist interpretation, you must use codes from the series 88271-88275 (Molecular cytogenetics ...).

The National Correct Coding Initiative Policy Manual states that "a physician (MD/DO) ... [must] quantitate ... and interpret the tissues/cells stained with the [ISH] probe(s)" for you to use 88365-88368.

According to the AMA in CPT Changes 2005: An Insider's View, you should use 88365-88368 only when the pathologist performs the selection and interpretation steps of the procedure. Specifically, the pathologist's role must be "first determining the appropriate areas of the tumor to evaluate, ... and then interpreting the [results]" of the cell/probe signal counts.

Medicare Part B, nor any payer that we're aware of, covers PhD lab professional services as physician professional services.

Fee schedule hint: Medicare pays for 88365-88368 on the physician fee schedule, but pays for 88271-88275 on the clinical lab fee schedule. The payment schedules help distinguish physician services from lab services performed without a direct physician diagnostic interpretation and medical decision making.