Wiki 88360

[necruz]

We just now started to do the ER/PgR/Her2/Ki67 stains in house. Is it correct to bill 88360 x 4 (for each stain)? Is it also correct to bill the same stains again with the other immunohistochemical stains performed as 88342/88341? Please advise - Thanks

 

[rae3613]

It is correct to bill as 88360 if they are reported with quantitative or semiquantitative results. E.g. 'Ki67 labels 40 to 50 % of the tumor cells' If there are no quantitative results, then you will need to bill with 88342/88341.
I'm not sure I understand your second question. You wouldn't bill twice for the same IHC stains but you can bill it with other IHC stains billed with 88342/88341.

 

[necruz]

Thank you rae3613 - The report does have the quantitative results so we will bill 88360 x 4. Let me clarify my 2nd question - the report i am looking at involved only the Left Breast and it had other IHC stains (ex e-cadherin, p40, p63 and a few others) including the ER/PgR/Her2/Ki67 quantitative results. It has been brought up that the ER/PgR/Her2/Ki67 stains can also be billed as IHC stains and therefore we can also bill them as 88342/88341 stains. I disagree and i need clarification. Thanks

 

[rae3613]

Oh ok. 88360 is already billing for the IHC stains (with quantitative results). In the CPT under both 88360 and 88342/1 it states ‘Do not report 88342/1/88344 in conjunction with 88360 unless each procedure is for a different antibody.’
You cannot bill both 88360 and 88342 for the same IHC On the same specimen.

 

[danachock]

Hi necruz
I somewhat disagree that the ER/PR/HER2/Ki-67 can also be billed as IHC stains. Please let me explain.
If the ER and PR performed are quantitative (as stated above) - you will bill 88360. (Just so everyone knows the ER and PR can be performed as an IHC and not just quantification).
HER2 and Ki-67 are quantitative both being billed with 88360.
Ki-67 is quantitative even if the number is zero. It will state something like <0 (which is still a quantitative percentage; there however was nothing to find). Bill it 88360.
(HER2 is not IHC) - HER2 can be quantitative (88360); and if the test is "equivocal" a FISH "reflex" may be ordered billing 88377.
The other stains mentioned above - the E-cadherin you will bill with 88342 with XU modifier, p40 bill with 88341 with XU modifier, p63 bill with 88341 with XU modifier, and any other IHC stains performed bill with 88341 with XU modifier. Please make sure your pathologist's is stating why these tests are performed in either the microscopic area or the IHC table to "rule out, rule in, validate xxxxx, confirm xxxxx, etc..." if you are ever faced with a denial. These IHCs are used to differentiate on the kind of cancer the patient may have and any invasions. This is useful information for the treatment plan for the patient - lumpectomy, mastectomy, radiation, chemotherapy (what type/for how long). If we don't know exactly what type of cancer the patient has it becomes difficult to come up with an effective treatment plan for curative care.
Please reach out with any additional questions and have a great evening.
Thank you for listening,
Dana

 

[necruz]

Hi Dana -- You have been a tremendous help. I appreciate your feedback. In regards to the XU modifier, is that for all insurances (Commercial and Medicare) that it can be used on or only Medicare? Thank you.

 

[danachock]

Hi necruz
We follow Medicare guidelines where I work for all payors (commercial, Medicare, or otherwise). If 88360 is billing with 88342 or 88341 we will apply XU modifier to both 88342 and 88341 charges for every patient regardless of their health insurance. The XU modifier is more specific for this scenario.
Have a wonderful evening,
Dana

 

[necruz]

Thank you Dana. Have a great week.

 

[raphaguz@yahoo.com]

Hi Dana. I'm new to pathology and was wondering if you could help me with a question. We usually bill these 88360 and apply XU to 88342 and 88341 per MUE and NCCI. Now, if the report has an addendum by a different provider and performs 8 more units of IHC (different tests than original ones) on the same block, is it okay to bill 88342.XP and 88341.XP? Should we only bill 88341.XP as corrected claim even though it's a different provider? Any information would help.

 

[danachock]

Hi raphaguz@yahoo.com,
Well, your question has a little bit of a twist - let me try describing the scenarios okay. When was the addendum performed? Was it within the 30 days of acquiring the specimen or after?
I'm going to give another off the top of my head this seriously doesn't exist coding scenarios for this example okay. That 30-day timeline is very important. Please be very cognizant when coding charges from an addendum. There is quite a bit here to provide and I will try to include it all, but please if I have missed something - do not be afraid to question me okay.
First example - breast core biopsy obtained on 08/01/2022 from Dr. Kermit and pathologist performed their interpretation including ER+, PR-, HER2 (equivocal), Ki-67 <80% tumor cells, and also applied a p63 and SMA (smooth muscle actin). We would bill this 88305 (breast core), 88360x4 for the ER, PR, HER2 and Ki-67, along with both 88342 and 88341 (with appropriate modifiers) that was professionally interpretated by J Wayne.
Addendum happens within the 30 days of the initial biopsy received and now 8 additional immunohistochemical stains are applied by a different pathologist for their professional interpretation by Dr Fonzy. In my professional opinion you would bill this as 88341x8 with modifier XP for separate provider. These new stains will still have the same collection date of 8/1/2022 and since you are billing 88341x8 for these new stains doesn't fix anything. Yes, you can bill it out all day long if you would like but your professional charges are going to be denied. Clearly these charges are later than the original ones and are now "solo" without a primary 88342 charge. To sum it up - you are billing 88341x8 without the primary CPT code. I do not know what system you utilize. I can only offer if that this happened in EPIC, I would correct the original invoice and manually add these charges to the existing charges. Do not wait for the denial (I have seen too many cases where "add on charge" was billed without primary charge to change my mind) on this event this evening.
Next scenario that the addendum that was past the 30 days. Are you closely watching your charges? Are you sure that those new 8 immunohistochemical stains are on a BRAND NEW HAR WITH THE CORRECT DOS (Date of service) - the date that the provider ordered that testing to be performed? If not, this is clearly not a coding issue here. You need to reach out to your supervisor for assistance. (If they taught you or gave you a contact for this scenario to contact ~ that is what you use). We are beyond that "30 days" and it has to be all on its own".
I am going to use the original scenario but just update the DOS to 9/10/2022 the date that Dr. Kermit ordered that additional testing to explain the differences here okay. We have a brand new HAR created, and provider Dr. Kermit stated he wanted 8 additional IHC's provided to specimen to rule out, rule in, or otherwise. He is fantastic and will explain why these new 8 additional IHC's are being applied to appeal in his documentation. Pathology department receives the request that is promptly fulfilled. A brand-new addendum dated 9/15/2022 states that due to additional IHC studies requested by Dr. Kermit that (AGAIN I am so very fictious here again) CAM 5.2, CD3, CD5, Kappa, Lambda, TTF-1, CD3, CD4 was applied for professional interpretation by (Dr. Cookie Monster). This is billed with 88342x1 with 88341x7 on the same invoice. I am not telling anyone to quantity bill or line-item bill (that is your facilities preference). I am merely telling you that this is the information your healthcare facility is faced with now.
Again, I apologize if I missed anything and please everyone reach out here. There is a lot of information and I want to be sure nothing fell through the cracks.
Have a wondaful evening,
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB, RHIT

 

[aamipatel]

Hi, this discussion forum is helpful, explaining a lot regarding 88360. Wondering about, we can still use 88360 for use of Ki-67 if the specimen is not of Breast but of GI location.

 

[danachock]

Hello aamipatel,
Yes, you may. I apologize for my delay. I believe I have information that may assist you for proper CPT coding assignment.
Again, yes, 88360 may be clearly used for other areas of the body. I see it in other areas including brain specimens.

Oh goodness, maybe it is time I address the immunohistochemical stains. Qualitative versus Quantitative here today.
I am clearly not here to push someone into attending my pathology presentation, but this is something that I do cover in my pathology presentation(s).
Just having the opportunity for me to speak out loud with my knowledge versus typing words in this post is completely night and day here.

Let me provide the basics a pathology coder needs to know on the difference between Qualitative (88342) and Quantitative (88360). There are other CPT code variations of course but let's stick with the basics from our CPT book for my examples okay.

First let me discuss Qualitative immunohistochemical stains:
A pathologist applies an immunohistochemical stain and reviews it (with appropriate controls) and is able to determine if the result is positive or negative. That is an 88342 charge.
Qualitative can be a positive result, negative result or just noncontributory due to several different reasons.

Fictious Examples to share:
Immunohistochemical stain for Helicobacter (H Pylori) is positive. This is billable
ALK1 immunohistochemical stain is negative. This is billable
Immunohistochemical stain for EMA is positive. This is billable
TTF-1 immunohistochemical stain is positive. This is billable
CDX-2 immunohistochemical stain is noncontributory. Not billable

Next let's review quantitative immunohistochemical stains:
A pathologist applies an immunohistochemical stain and reviews it and quantifies the tumor cells. Please do not be confused on this. If the pathologist’s is counting tumor cells this is totally appropriate, but if they are quantifying other things that is clearly NOT NEOPLASTIC related; this is not your coding route.

Let’s review the CPT book on what 88360 states “Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure, manual”.
The pathologist actually counts the tumor cells identified and provides it in a percentage or a number.

Again, more Fictious Examples to share:
Ki-67 proliferation index is <4%. This is billable
Estrogen Receptor at <10%. This is billable
Progesterone Receptor <75%. This is billable
PD-L1 with <1% no PDL expression. This is billable
HER2 is equivocal. This is billable

Again, let me reiterate that you need to be super careful reviewing the pathology report. Was the immunohistochemical stain positive or negative? Or not billable due to being noncontributory.
Next, the quantification of an immunohistochemical stain for tumor. Were tumor cells actually counted? Do you have the proof to support billing CPT 88360 (or CPT code) due to my simple discussion.
When in doubt; I need you to please query, ask your pathologist’s what was being evaluated and why. Some of the pathologist’s I have met in my pathology career have been such great teachers and have explained things in such simple manner. The pathologist(s) I have met in my career have been so kind. They love discussing pathology. Please do not be afraid to ask a question. You know asking a question and communicating is a two way street. You ask something and they share but if they are faced with a "whopper" ~ they in return will possibly ask for your guidance on some coding assistance.



Have a fantastic evening,
Dana

 

[sdaniels]

Hi Dana,

Would this be 88342 or 88360?

 

[danachock]

Hello and Good Evening sdaniels;
You brought up a very great immunohistochemical coding point today.
May I break it down in the terms that I code?
There are two primary immunohistochemical stains (those that are qualitative and those that are quantitative) "clearly" among others here. The focus this evening is on just these two scenarios okay.
88342 is primary procedure with 88341 the add on - those are qualitative. The pathologist applied an immunohistochemical stain and it is either "positive or negative".
I am reviewing your example - positive for Mammoglobin, AE1/AE3, ER, PR and are negative for HER2. There is only positive and negative discussed here. It is 88342/88341. No one has quantified anything.

No worries let's review 88360 (I look at my CPT book all the time that the majority of my pathology pages have been ripped out). Let us review 88360. It states in our CPT book that it is "morphometric analysis, tumor immunohistochemistry (eg, Her2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen each single antibody stain procedure, manual. It has to be presented quantitative; a numerical number like a percentage or value or otherwise (a quantitative number has to be provided). If someone (pathologist's) states that it is "low" that is not sufficient to bill 88360 CPT assignment here. Again; quantification is the rule of thumb. If you are billing 88342 with 88360 you are probably appealing it all; may want to be sure you have it documented to receive the entitled reimbursement (RVUS).
I hope this helps shed light on your coding woes, please reach out if you need additional assistance.
Dana

 

[sdaniels]

Hello and Good Evening sdaniels;
You brought up a very great immunohistochemical coding point today.
May I break it down in the terms that I code?
There are two primary immunohistochemical stains (those that are qualitative and those that are quantitative) "clearly" among others here. The focus this evening is on just these two scenarios okay.
88342 is primary procedure with 88341 the add on - those are qualitative. The pathologist applied an immunohistochemical stain and it is either "positive or negative".
I am reviewing your example - positive for Mammoglobin, AE1/AE3, ER, PR and are negative for HER2. There is only positive and negative discussed here. It is 88342/88341. No one has quantified anything.

No worries let's review 88360 (I look at my CPT book all the time that the majority of my pathology pages have been ripped out). Let us review 88360. It states in our CPT book that it is "morphometric analysis, tumor immunohistochemistry (eg, Her2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen each single antibody stain procedure, manual. It has to be presented quantitative; a numerical number like a percentage or value or otherwise (a quantitative number has to be provided). If someone (pathologist's) states that it is "low" that is not sufficient to bill 88360 CPT assignment here. Again; quantification is the rule of thumb. If you are billing 88342 with 88360 you are probably appealing it all; may want to be sure you have it documented to receive the entitled reimbursement (RVUS).
I hope this helps shed light on your coding woes, please reach out if you need additional assistance.
Dana

Thank you so much Dana. That's what I thought. If there isn't a percentage or a value, then 88360 is not appropriate. I'm struggling in this area. Can you look at the codes below and verify which set is correct for the above scenario? There is a discrepancy between what I coded and what another person coded: (88305 X 2, 88342 X 2, 88341 X 8) vs (88305 X 2, 88342 X 2, 88341 X 6, 88360 X 2 )or (88305 X 2, 88342 X 2, 88360 X 6)?

 

[danachock]

Hello sdaniels,
Again, I will try to assist you. From the final interpretation without seeing the gross or microscopic I cannot clearly tell the difference between 88305 or 88307. I'd like to pretend it is a punch skin biopsy, but I really do not know reviewing the information provided. The gross and microscopic (with no PHI would assist). The reason(s) why I state this is because ~ let's review specimen A & B together with this information.
Were these skin biopsies, or breast lesions with margins reviewed?
A) states within the final interpretation that "patient's history of breast carcinoma, extending to peripheral margin"
B) states within the final interpretation that "patient's history of breast carcinoma, extending to peripheral & deep margins"

Next let's discuss the immunohistochemical stains:
Specimen A:
Mammoglobin, AE1/AE3, ER, PR, HER2 were either positive or negative (no quantification provided)
Specimen B:
Mammoglobin, AE1/AE3, ER, PR, HER2 were either positive or negative (no quantification provided)

Coding stains can be horribly cumbersome sometimes, so I'll walk you through this.
Specimen A: You bill 88342x1 for the Mammogloblin, 88341x4 (for the AE1/AE3, ER, PR, HER2)
Specimen B: You bill 88342x1 for the Mammogloblin, 88341x4 (for the AE1/AE3, ER, PR, HER2)

Let me summarize:
If this was a skin for example punch biopsy from two different sites we would bill at the end of the day
88305x2
88342x2
88341x8

If this was deemed a breast lesion with margins reviewed (not shared so unsure here???)
88307x2
88342x2
88341x8

Again, let me reiterate what I know. If the immunohistochemical stain is postive or negative (it is a qualitative stain). The first charge is billed with 88342 with subsequent charges billed with 88341.

If someone felt that 88360 (from your example above) was warranted to be billed it CLEARLY should have been displayed within the pathology report in a quantitative state (%, numerical, or otherwise here).
There is absolutely no way to support 88360 with a positive or negative finding unless you have THAT NECESSARY QUANTIFICATION. (If it was the pathologist's questioning ~do not be shy, many are so incredibly kind, just explain that you need a quantitative state to capture RVU's for getting CPT 88360 if you possibly felt they missed that opportunity.
Most do not know. Our pathologist's work super hard, and long. If I recall correctly from one of my pathologist mentors during their 8 years of training, they get that one "class in school". It clearly in my logistics isn't enough. It is a constant open communication line here from me. Since 2012 to now I still appreciate the opportunity to discuss new pathology trends
I am going to give a shout out to all those billers that appeal these scenarios. This is again the stuff that keeps me up at night and absolutely applaud every single one of you!!
The CCI edits are flooding appeals FOR ALL PAYORS because 88342, 88341 doesn't play well with 88360. Some billers have been there for so long and have taken the authority to "just" write stuff off if it is small enough and no one cares. I had so many denials that 88342 was denied because of 88360 so they wrote off the 88342 (small dollar amount I am guessing??) and now I had to deal with the other copious amounts of 88341 charges that were denied. I can provide fictious examples of this of course.
I apologize for being lengthy,
Please reach out to me if you have any questions.
Or PM me, if necessary, okay
Dana

 

[sdaniels]

Hello sdaniels,
Again, I will try to assist you. From the final interpretation without seeing the gross or microscopic I cannot clearly tell the difference between 88305 or 88307. I'd like to pretend it is a punch skin biopsy, but I really do not know reviewing the information provided. The gross and microscopic (with no PHI would assist). The reason(s) why I state this is because ~ let's review specimen A & B together with this information.
Were these skin biopsies, or breast lesions with margins reviewed?
A) states within the final interpretation that "patient's history of breast carcinoma, extending to peripheral margin"
B) states within the final interpretation that "patient's history of breast carcinoma, extending to peripheral & deep margins"

Next let's discuss the immunohistochemical stains:
Specimen A:
Mammoglobin, AE1/AE3, ER, PR, HER2 were either positive or negative (no quantification provided)
Specimen B:
Mammoglobin, AE1/AE3, ER, PR, HER2 were either positive or negative (no quantification provided)

Coding stains can be horribly cumbersome sometimes, so I'll walk you through this.
Specimen A: You bill 88342x1 for the Mammogloblin, 88341x4 (for the AE1/AE3, ER, PR, HER2)
Specimen B: You bill 88342x1 for the Mammogloblin, 88341x4 (for the AE1/AE3, ER, PR, HER2)

Let me summarize:
If this was a skin for example punch biopsy from two different sites we would bill at the end of the day
88305x2
88342x2
88341x8

If this was deemed a breast lesion with margins reviewed (not shared so unsure here???)
88307x2
88342x2
88341x8

Again, let me reiterate what I know. If the immunohistochemical stain is postive or negative (it is a qualitative stain). The first charge is billed with 88342 with subsequent charges billed with 88341.

If someone felt that 88360 (from your example above) was warranted to be billed it CLEARLY should have been displayed within the pathology report in a quantitative state (%, numerical, or otherwise here).
There is absolutely no way to support 88360 with a positive or negative finding unless you have THAT NECESSARY QUANTIFICATION. (If it was the pathologist's questioning ~do not be shy, many are so incredibly kind, just explain that you need a quantitative state to capture RVU's for getting CPT 88360 if you possibly felt they missed that opportunity.
Most do not know. Our pathologist's work super hard, and long. If I recall correctly from one of my pathologist mentors during their 8 years of training, they get that one "class in school". It clearly in my logistics isn't enough. It is a constant open communication line here from me. Since 2012 to now I still appreciate the opportunity to discuss new pathology trends
I am going to give a shout out to all those billers that appeal these scenarios. This is again the stuff that keeps me up at night and absolutely applaud every single one of you!!
The CCI edits are flooding appeals FOR ALL PAYORS because 88342, 88341 doesn't play well with 88360. Some billers have been there for so long and have taken the authority to "just" write stuff off if it is small enough and no one cares. I had so many denials that 88342 was denied because of 88360 so they wrote off the 88342 (small dollar amount I am guessing??) and now I had to deal with the other copious amounts of 88341 charges that were denied. I can provide fictious examples of this of course.
I apologize for being lengthy,
Please reach out to me if you have any questions.
Or PM me, if necessary, okay
Dana

Hi Dana, I can't thank you enough for your help with this one. I was right! I hope it's okay if I contact you in the future, should I have any other difficult cases. Thank you! I appreciate your thorough explanation!
Thanks again, Stacey

 

[danachock]

Hi Dana, I can't thank you enough for your help with this one. I was right! I hope it's okay if I contact you in the future, should I have any other difficult cases. Thank you! I appreciate your thorough explanation!
Thanks again, Stacey

You are very welcome, Stacey ~
I am super pleased that I was able to assist. If you ever need anything, please feel free to reach out.
Have a fantastic evening!
Dana

 

[sdaniels]

You are very welcome, Stacey ~
I am super pleased that I was able to assist. If you ever need anything, please feel free to reach out.
Have a fantastic evening!
Dana

Hi Dana,

I'm back! What about this one? I have 88305, 88342, 88341. Is there something for the melanoma profile?

 

[danachock]

Hello sdaniels
No, there is nothing from your post that has additional immunohistochemical stains. Your post only discusses SOX-10 with PRAME warranting 88342x1, 88341x1.
Goodness: that may be a great question to pose to your pathologists though. The reason I simply state that is because I have pathologist's that use "melanoma markers" that contain "Melan-A, HMB-45, with SOX-10" and by chance what if one was in error omitted here? Pathologists are super busy. Be the radar. From my review it was two stains 88342 with 88341x1 but what if something was missing, right?
You stated to review the melanoma profile; there is nothing there to even bill an immunohistochemical stain. It was all within their final interpretation.
Every pathologist's documents differently. That is not a coders problem. That is a facility problem not having auto fill or smart text's or auto fill in information readily available to make things uniform. Uniform isn't a new concept here. I'm all about RVUs for my pathologist's but tell me where you want me to focus my coding attention to. You state melanoma profile; that doesn't contain one stain. Not ideal for RVU's here.
I'm hopeful I provided some feedback here.
Not exactly had planned but I'm not one to sugar coat something when something seems amiss here.
Dana

 

[sdaniels]

Hello sdaniels
No, there is nothing from your post that has additional immunohistochemical stains. Your post only discusses SOX-10 with PRAME warranting 88342x1, 88341x1.
Goodness: that may be a great question to pose to your pathologists though. The reason I simply state that is because I have pathologist's that use "melanoma markers" that contain "Melan-A, HMB-45, with SOX-10" and by chance what if one was in error omitted here? Pathologists are super busy. Be the radar. From my review it was two stains 88342 with 88341x1 but what if something was missing, right?
You stated to review the melanoma profile; there is nothing there to even bill an immunohistochemical stain. It was all within their final interpretation.
Every pathologist's documents differently. That is not a coders problem. That is a facility problem not having auto fill or smart text's or auto fill in information readily available to make things uniform. Uniform isn't a new concept here. I'm all about RVUs for my pathologist's but tell me where you want me to focus my coding attention to. You state melanoma profile; that doesn't contain one stain. Not ideal for RVU's here.
I'm hopeful I provided some feedback here.
Not exactly had planned but I'm not one to sugar coat something when something seems amiss here.
Dana

Thank you so much! I agree! Merry Christmas and Happy New Year!

 

[sdaniels]

Thank you so much! I agree! Merry Christmas and Happy New Year!

Hi Dana,

I'm back with another question. Would this be 88305, 88342 (AE1/AE3), 88341 (GATA3) and 88360 X 3 ER,PR, Her2)?

 

[danachock]

sdaniels ~ you nailed it! you have the coding spot on!

If anyone else was wondering why I state that.
First, Let's look at the body of pathology report. We all know AE1/AE3, GATA3, ER, PR and HER2 were performed.

Seriously, look at the rest of the pathology report to support those charges. THOSE ARE RVU'S to our pathologist's.
Before any coder removes a charge; did you exhaustively review the pathology report?
If you work in my field. Did you review documentation and actually take the time to scroll through the ENTIRE rest of it?

I do not normally sugar coat stuff, but this pathology coding scenario makes me believe I need to be here.
You NEED TO SCROLL POLITILEY TO THE BOTTOM TO CAPTURE THE 88360. The Biomarkers Profile area.
If you don't understand Morphometric just please tell me so.

I am hopeful that I was helpful, I am a little unsure why my text is in bold but if displayed, apologize now.

​

 

[sdaniels]

sdaniels ~ you nailed it! you have the coding spot on!​

​

If anyone else was wondering why I state that.​

First, Let's look at the body of pathology report. We all know AE1/AE3, GATA3, ER, PR and HER2 were performed.​

​

Seriously, look at the rest of the pathology report to support those charges. THOSE ARE RVU'S to our pathologist's.​

Before any coder removes a charge; did you exhaustively review the pathology report?​

If you work in my field. Did you review documentation and actually take the time to scroll through the ENTIRE rest of it?​

​

I do not normally sugar coat stuff, but this pathology coding scenario makes me believe I need to be here.​

You NEED TO SCROLL POLITILEY TO THE BOTTOM TO CAPTURE THE 88360. The Biomarkers Profile area.​

If you don't understand Morphometric just please tell me so.​

​

I am hopeful that I was helpful, I am a little unsure why my text is in bold but if displayed, apologize now.​

​

​

Thank you, Dana! You have been so helpful! I actually missed this one originally, so I'm glad there is such a thing as charge correction! Thanks again!

 

[Narobo]

We just now started to do the ER/PgR/Her2/Ki67 stains in house. Is it correct to bill 88360 x 4 (for each stain)? Is it also correct to bill the same stains again with the other immunohistochemical stains performed as 88342/88341? Please advise - Thanks

Just be certain each of the 4 stains in question also state “manual morphometry” within the report to support billing 88360’s. A numerical value is not enough to support 88360 as ER, PR, and Ki67 can also all be read by image analysis!

 

[Narobo]

Hi Dana,

I'm back with another question. Would this be 88305, 88342 (AE1/AE3), 88341 (GATA3) and 88360 X 3 ER,PR, Her2)?View attachment 7015

Be sure that it stays “manual morphometry” within the report somewhere as well. Otherwise your 88360 charge is not supported! A numerical value alone is not enough to support the charge, you must have the method documented as well!

 

[Narobo]

Hello Narobo,
I will bill 88360 if tumor cells were quantified. I will appeal charges all day long. You need the numerical value %, <, >, or = to 1, 2, 3 with the disclaimer (key) on why; or possibly greater than 90%, 80%, 20% or otherwise to support billing this. It has to be quantified and I feel that I fully understand the pathology report to explain to the denial and billing team what needs to be done here to appeal this. Majority of the denials I worked at was supporting billing 88342 with 88341 with 88360.
Thank you for the insight and have a wonderful evening,
Dana

I agree with you that a numerical value does warrant an 88360 OR and 88361. However, the method that you use to read/interpret these stains (manual vs computer-assisted) also needs to be documented within the pathology report to support the charge. This is listed in the APF handbook under the 88360/88361 portion in section 6. You can definitely always come back and appeal a denial, but if you have the information at hand with how the stain was interpreted, all the better to add that to the report ahead of time so you are less likely to be met with a denial.

 

[danachock]

You are absolutely correct Narobo. Please be cognizant, not everyone has access to the APF manual here. Explain it in simple terms.

 

[NishitaKunta]

Hello Dana
This is my first time posting on AAPC wiki and i hope i am posting my query correctly so you can see it. I am a newbie to Pathology specialty . I came across a patient complaint where she felt she overpaid and the case was transferred to accounting. I have posted a few slides of the report. For the charges which were submitted, the insurance denied it by saying 88334 is incidental to 88332 , 88342 is incidental to 88360 . Can you kindly explain these two denials/incidentals for me? i submitted the charges as 88307 X 7, 88305 X 6, 88360, 88334, 88332, 88331, 88342 X 5, 88341 X 4 . and if there is anything which do not look right can you kindly help me with it ?
I would Truly appreciate .

 

[danachock]

Hello nishita75@yahoo.com
I will try to access this case your case and break it down okay.
Specimen 1 was a sentinel node with frozen section and touch prep with pankeratin immunohistochemical stain (88307, 88331, 88334, 88342)
Specimen 2 was a sentinel node with frozen section and pankeratin (88307, 88331, 88342)
Specimen 3 was 88307
Specimen 4 was probably an 88307 but would fall back on 88305 (because I do not see documentation that margins were stained or evaluated in the gross or microscopic areas of pathology report)
Specimen 5 was probably an 88307 but would fall back on 88305 (because I do not see documentation that margins were stained or evaluated in the gross or microscopic areas of pathology report)
Specimen 6 was probably an 88307 but would fall back on 88305 (because I do not see documentation that margins were stained or evaluated in the gross or microscopic areas of pathology report)
Specimen 7 was a sentinel node with pankeratin immunohistochemical stain (88307, 88342)
Specimen 8 was a sentinel node with pankeratin immunohistochemical stain (88307, 88342)
Specimen 9 was probably an 88307 but would fall back on 88305 (because I do not see documentation that margins were stained or evaluated in the gross or microscopic areas of pathology report)
Specimen 10 was probably an 88307 but would fall back on 88305 (because I do not see documentation that margins were stained or evaluated in the gross or microscopic areas of pathology report)
Specimen 11 was a sentinel node with pankeratin immunohistochemical stain (88307, 88342)
Specimen 12 was probably an 88307 but would fall back on 88305 (because I do not see documentation that margins were stained or evaluated in the gross or microscopic areas of pathology report)
Specimen 13 88307 with 88342 with 88341x2
I do not have the ability to see what you are seeing within the entire pathology report, like gross description (what was inked), Margins are so extremely important for any neoplastic process. I am not a fool but sometimes pathologists don't document what you need to apply an 88307 "checking margins here" versus 88305 "crickets" here.
If anyone disagrees with my breakdown here on this coding scenario, this would be the time to state it please. I broke it down in specimen parts. I don't have gross or microscopic, so I get to leave it up to the coders that review that stuff to decide the CPT assignment here.
This may be a learning curve??
Have a fantastic evening.
Dana

 

[NishitaKunta]

Hello Dana,
I truly appreciate your prompt response on my Query regarding so many different codes and the way you clarified it by explaining every specimen and the code which goes with it. With this I felt confident in posting some other queries about other specialties too in the forum. As you mentioned mine is a learning curve and I am still confused with so many situations. Actually in the case I posted , I had a doubt on Specimen 2 , should I enter a 88334 as this specimen also was treated with pankeratin ? I understand you did not have the Gross and Microscopic reports for this case. I did compile all those in one , but was unable to attach as it would not take the Word format.

Thanks Again

 

[danachock]

Hello nishita75@yahoo.com,
I am a little unsure on your question on 88334 here.
Maybe if you would kindly share with me why 88334 is warranted here. I don't have the full pathology report. So, I really do need your help to assist you okay. I really feel like I am missing something from the pathology report you are seeing, and I can't tell you if you are accurate or not with the little information I have.
If you could just grab the pieces out of the pathology report with no PHI that you are reviewing to drive reporting CPT 88334 for Specimen 2, please. All I saw was an immunohistochemical stain for Pankeratin was performed. Sentinel nodes can be a beast. I have seen both touch preps, squash preps and frozen sections or one of these without the others. I'm just trying to help.
The forums won't take any format. You compile it in a document. I prefer Word. You remove anything PHI related and you just copy and paste the stuff from your word document to the post. No need to load a document.
Listen, I am here for you. You can reach out to my Inbox and message me privately if you want to within the AAPC. Just so that everyone knows; I will not take that privilege away ever for any of my pathology colleagues!!
If you feel better in a closed door setting with only 143 people you can hop to our facebook page I created with my pathology colleagues last June "Pathology Coding Across the World" or you may find me in Messenger.
I want every pathology specialty coder to figure out the truth. What pathology charges are billable and exactly why. If you need help, post additional details or find me to help you okay please. Back in those growing years of my pathology specialty life and career. Help was so slim and super difficult to find. It didn't exist back in the day when I became a specialty pathology coder in 2012.
Let me know what you need and I will do everything I can to help you okay!
Dana

 

[mpurisima]

Hello,

I have searched the forums regarding this issue with 88360 however I was unable to find any posts. Is anyone encountering issues specifically with Blue Shield when billing 88360 and it being denied for experimental?

 

[danachock]

Hello mpurisima,
Isn't it the 55 (gosh this may be Aetna) or maybe 151 experimental thing from BCBS off the top of my head? I apologize, but it has been a while since reviewing denials here (over clearly a year).
I reviewed MCDs both A57611 and A57523 (Locate the policies and review yourself) and I am not seeing issues here therefore I am going to need to ask you what charges you billed.
Pathology report without PHI is the best way to gather important details but I'm fine with asking "what stains you actually billed" with no details.
BCBS is obnoxious. They have such insane policies. Not going to open that pandora's box (did anesthesia denials BCBS for both upper and lower endoscopic procedures and I was hmm "CORRECT").
I can summarize what I feel may be happening. The pathologist's billed 88342 with or without 88341 with 88360 and this is causing something inappropriate from Blue Shield. Were modifiers added to 88342 and 88341?
If that was the issue or not? If so which Modifier?
Was it one case? Or several? If it was several. For how long now?
I am clearly not an alarmist here. They just provided details for ICD updates for ICD 10 for October 1, 2024. I really do know why immunohistochemical stains were provided to neoplastic specimens.
Seriously, to identify and figure out the neoplastic process.
I also know why ER, PR, HER2 was potentially performed. Treatment plans moving forward all day long for our patient.
This next fall is going to be a heavy lift in my opinion for the pathology specialty. We not only have currently ER status Z17.x positive or negative but now in October the Progesterone Receptor and also HER2 Receptor.
I'm trying to assist you the best I know. I don't believe Blue Shield received the correct modifiers on all the charges here and they were buttheads. The reason I state that is because 88342 and 88341 require a modifier (secondary charge). 88360 would have been the primary procedure with these three charges. Why would they dump it off as experimental? I've done denials for years. There is either something billed wrong or Blue Shield lost their marbles and you get to appeal it all. No, joke. Seriously did that for like months for anesthesia.
I would not hesitate another moment here to ask my billing department, coding lead, integrity department, billing analyst, coding analyst, so forth. (Basically, your leadership) at your facility to step in and state what I am stating here. I have so much background and information. I am not wrong.
If what you are sharing is true. My responses would explain exactly why that it was denied erroneously.
Please let me know if you need anything else and have a fantastic evening.
Dana