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Julia Posted Fri 11th of December, 2015 16:26:53 PM

We send out our breast cases to a third party facility to perform Her2 FISH. They bill codes 88271 and 88274 x2. Medicare's LCDs do not support these codes for breast. Several carriers have adopted their policies. As such, we have patients getting their claims denied and this 3rd party lab is billing them the gross charges. Are these the correct codes for this procedure? If so, how are other laboratories dealing with reimbursement in their breast cases?

Julia Posted Fri 11th of December, 2015 16:27:42 PM

Correction, codes are 88271 x2 and 88274 x1.

SuperCoder Answered Mon 14th of December, 2015 03:09:54 AM

CPT codes are correct for this scenario. But as you have not documented diagnosis in your query, please refer below link to check medical necessity of payable diagnosis for 88271 and 88274 according to Medicare-

Julia Posted Tue 15th of December, 2015 12:45:14 PM

These are for breast tissue cases with the (typical) diagnosis of C50.XXX. According to this publication on your own site, they are not billing correctly While this publication is old, it does still reflect current CMS policy with regards to these codes not being supported for the diagnosis provided. However, I have seen other codes used for similar testing such as Quest charging 88368/9, Univ of Michigan charging 88377, and neo genomics charging 88374/7. These are also supported by CMS policy. Do you have an updated publication on this topic?

SuperCoder Answered Wed 16th of December, 2015 02:45:24 AM

SURGICAL PATHOLOGY IN SITU HYBRIDIZATION (I.E. FISH) These new clarified guidelines will require pathologist/laboratories to clearly document when a multiplex/ cocktail stained probe procedure has been performed for FISH. Unit of service for FISH is “per specimen, per separate single probe stain procedure.” NOTE that 88364 has a + sign denoting it is add- on code and can only be billed when 88365 is also billed. 88364 is for each additional probe “stain procedure” for a different antibody(s). Also note that add-on code in this instance is before the primary procedure code in number. AMA didn’t have an available code in this area to make add-on code come after the primary code in number like they normally do. So coders will have to pay CLOSE attention to make sure they don’t bill the wrong code as the primary and add on code. Finally, a new code to represent multiplex antibody probe stain procedure has been introduced (88366) to represent when a single probe stain procedure contains multiple antibodies on that given probe.

SURGICAL PATHOLOGY MORPHOMETRIC ANALYSIS - IN SITU HYBRIDIZATION these new clarified guidelines will require pathologist/laboratories to clearly document when a multiplex/ cocktail stained probe procedure has been performed for morphometric analysis by in situ hybridization. Unit of service for morphometric analysis by in situ hybridization is per specimen, per separate single probe stain procedure. Use code: • 88367 or 88368 (semi/quantitative--depending on manual versus computer assisted) for the first single probe stain procedure • 88373 or 88369 for semi/quantitative--depending on manual or computer assisted for each additional single probe stain procedure.
For multiplex staining procedures: Use 88374 or 88377 (semi/quantitative—depending on manual versus computer assisted) when multiple antibodies on a probe by a single staining procedure. The terms “single probe stain procedure” and “multiplex probe stain procedure” will play a vital part in the units of service as well as the code(s) that is selected.
Using the term single probe stain procedure indicates that the same probe that may contain multiple different antibodies on that probe must be assigned the code associated with multiplex probe stain procedure. It is the procedure that also determines the unit of service of that multiplex probe stain. If the probe(s) are performed in one single stain procedure, then you must consider that one unit of service for that multiplex probe. For example, if a morphometric analysis by in situ hybridization is performed with a dual probe containing two different antibodies on that single probe, reported in semi/quantitative value…that is one unit of service of 88374 or 88377 (depending on semi/quantitative--manual versus computer assisted).

Hope this helps. Also you can refer below updated publications on this topic-

Julia Posted Fri 18th of December, 2015 12:27:18 PM

The test is by Dako; HER2 IQFISH pharmDx™. With this information are you able to provide the exact CPT codes required for billing? If 88271-88275 are the correct codes, what can providers do when facing denials given Medicare LCD restrictions?

SuperCoder Answered Mon 21st of December, 2015 02:22:04 AM

Correct CPT codes are 88367x2

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