Wiki CPT Code 88360 Morphometric analysis Help

[eajenn]

I am reviewing a pathology report where the provider billed CPT Code 88360. The path report states "Immunohistochemical studies were performed on the second portion Duodenum Biopsy utilizing Lymphocytic markers CD3, CD8, and CD20. The panel reveals no evidence of CD3+CD8+T Cell Intraepithelial Lymphocytosis in surface Epithelium, especially in tips of Villi. No abnormal distribution of CD20+ B-Lymphocytes is present." I am not sure what I need to be looking at in this finding to confirm that CPT Code 88360 was performed. The provider billed CPT Code 88342 x 1 unit and CPT Code 88360 x 2 units. Both codes were billed with Mod -59.

Can anyone direct me to information to help me determine if CPT Code 88360 was performed? Also, the report does not state manual of computer-assisted. Shouldn't that also be documented?

Thank you in advance for help

 

[bbooks]

You are correct. The documentation for 88360 is lacking.

Here is a good article. Although the article is from 2014 and the descriptions of the CPT codes has changed slightly, the description of the procedure and the documentation needed is still accurate.

http://apsmedbill.com/newsletters/2014-08/quantitativesemi-quantitative-ihc-cpt-coding

 

[eajenn]

You are correct. The documentation for 88360 is lacking.

Here is a good article. Although the article is from 2014 and the descriptions of the CPT codes has changed slightly, the description of the procedure and the documentation needed is still accurate.

http://apsmedbill.com/newsletters/2014-08/quantitativesemi-quantitative-ihc-cpt-coding

Thank you!