brodell pathmohsihc coding - 2016 sam handout€œif the mohs surgeon additionally stains one or...

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Copyright © 2016 American Academy of Dermatology. All rights reserved.

Dermatopathology, Immunohistochemistry,

and Mohs Coding Guidelines

Robert Brodell, MD 2016 AAD Summer Academy Meeting


Robert T. Brodell, MD

DISCLOSURES I do not have any relevant relationships with industry.

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I AM JUST THE MESSENGER


How is “Specimen” defined?

CPT 2016 Definition: Specimen (1) “A specimen is defined as tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis.” The above definition precedes the 88300 – 88309 histopathology code series. However, the definition is applied to all other pathology codes that include the word specimen in their descriptors.

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Definition of “Specimen”

CPT 2016 Definition: Specimen (2) “Two or more such specimens from the same patient (eg, separately identified endoscopic biopsies, skin lesions) are each appropriately assigned an individual code reflective of its proper level of service.” Mohs surgery: what constitutes a separately identified skin lesion?

Examples to follow.


Dermatopathology

CPT 2016 Definitions: Dermpath 88305 Surgical pathology, gross and microscopic examination 88304 Surgical pathology Cysts, Lipoma, and Skin Tags, gross and microscopic examination


Dermatopathology

CPT 2016 Definitions: Dermpath 88312 Surgical pathology, special stain for organism (e.g. PAS, GMS, silver stain) 88313 Surgical pathology, other stains (e.g. mucin)


Controversy

CPT codes do not distinguish between a tiny punch or shave biopsy and deep/wide skin excision that is based on “averaging” principle (both are 88305). Despite large time/work consuming cases with multiple blocks, the fairness principle should not be applied to CPT coding.

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Can these codes ever be used in Dermatopathology????

CPT 2016 Definitions: 88307 Surgical pathology, gross and microscopic examination

requiring microscopic evaluation of surgical margins (deep excision/re-excision without tumor)

88309 Surgical pathology, gross and microscopic examination

requiring microscopic evaluation of surgical margins (deep excision/re-excision with tumor)

NOTE: 88307 and 88309 have been extrapolated from “soft tissue” CPT coding by some dermatopathologists for excisions that include subcutaneous fat. However, according to the UMHS’s Specimen to Charge Code Rapid Finder List this should only be used when “the excision is so deep that any other layer of skin is incidental to the dominant subcutaneous tissue and /or muscle that comprises the true specimen.”


How do you interpret this?

In general, most coding consultants recommend no higher CPT code level than 88305 for any specimen that translates to a “skin” ICD-9-CM diagnosis code. NOTE: CMS does permit upcoding as long as the documentation can be substantiated by the provider….


Immunohistochemistry (IHC)

CPT 2016 Definitions: IHC (1) 88342 Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure 88341 each additional single antibody stain procedure

(List separately in addition to code for primary procedure)



CPT 2016 Definitions: IHC (2) 88344 each multiplex antibody stain procedure (Do not use more than one unit of 88341, 88342, or 88344 for the same separately identifiable antibody per specimen)

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CPT 2016 Definitions: IHC (3) (When multiple separately identifiable antibodies are applied to the same specimen [ie, multiplex antibody stain procedure], use one unit of 88344) (When multiple antibodies are applied to the same slide that are not separately identifiable, [eg, antibody cocktails], use 88342, unless an additional separately identifiable antibody is also used, then use 88344)


One block, separate antibody stains

Melanoma A)  S-100 B)  HMB-45 C)  Melan-A (Mart-1) D)  Ki-67_

De-Andrade BA, et al. Med Oral Patol Oral Cir Bucal (2012) Open-access

DC

A B


CPT Coding

De-Andrade BA, et al. Med Oral Patol Oral Cir Bucal (2012) Open-access

One specimen, four separately processed antibody stains Stain A: CPT 88342 Stain B: CPT 88341 Stain C: CPT 88341 Stain D: CPT 88341 (each 88341 billed on a separate line)

DC

A B


Multiplex Antibody IHC Stain

Pan melanoma + S-100 Ø  Two separately identifiable

antibodies in one application

Ø  Two stain colors differentiate the two antibodies

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CPT Coding

Pan melanoma + S-100 One specimen, two separately identifiable stains Code: CPT 88344


Antibody Cocktail IHC Stain

Cocktail: Ø  Two antibodies mixed

together, one stain

Ø  Individual antibodies cannot be separately identified


CPT Coding

Cocktail: Two antibodies, one stain: Individual antibody staining cannot be differentiated Code: CPT 88342

Pancytokeratin AE1/AE3 Spindle cell SCC


Immunohistochemistry (IHC): Mohs

NCCI Policy Manual for 2016, chapter 3 (effective 1/1 2016) -- Part 1

“If a Mohs surgeon removes a tumor specimen and divides it into multiple pieces of tissue, creates a block from each piece of tissue, and stains one or more blocks from that specimen with an initial single antibody immunohistochemistry stain, the Mohs surgeon should report only one (1) unit of service (UOS) of CPT code 88342 (Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure). Only one (1) UOS of CPT code 88342 may be reported per specimen.”

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“If the Mohs surgeon additionally stains one or more blocks from that specimen with an additional different single antibody immunohistochemistry (immunocytochemistry) stain, CPT code 88341 (immunohistochemistry or immunocytochemistry, per specimen/ each additional single antibody stain procedure (List separately in addition to code for primary procedure) may be reported with one (1) UOS per different antibody stain procedure. The UOS for these codes is not each block derived from a single specimen.”


IHC: Mohs Crucial Concept (1)

NCCI Policy Manual for 2016, chapter 3 (effective 1/1 2016)

“The UOS for these codes is not each block derived from a single specimen.”


IHC: Mohs Crucial Concept (2)

NCCI Policy Manual for 2016, chapter 3 (effective 1/1/2016)

“If the Mohs surgeon additionally stains one or more blocks from that specimen with an additional different single antibody immunohistochemistry (immunocytochemistry) stain, CPT code 88341 (immunohistochemistry or immunocytochemistry, per specimen/ each additional single antibody stain procedure (List separately in addition to code for primary procedure) may be reported with one (1) UOS per different antibody stain procedure.”

Bold added to original text for emphasis




“The UOS for these codes is not each block derived from a single specimen.”

1 2

3 4 = One specimen

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How do you code it? Example 1

1 2

3 4

First stage of Mohs, lentigo maligna, cheek o  One tissue layer excised o  Quadrisected o  Each piece placed upon a separate block, and separate slides made

Slides from each block are stained with: §  H & E §  Melan-A


Example 1

1 2

3 4



Your answer: 17311 – Mohs surgery, first stage 88342 – Immunohistochemistry,

one specimen, one stain

Is this correct?


Example 1

1 2

3 4



Your answer: 17311 – Mohs surgery, first stage 88342 – Immunohistochemistry,


Incorrect! Why??


NCCI column 1/column 2 edits

1731188342 20070101 * 1

Misuse of column two code with column one code

CCoolluummnn 11

CCoolluummnn 22

** == IInn eexxiisstteennccee pprriioorr ttoo 11999966

EEffffeeccttiivvee DDaattee

DDeelleettiioonn DDaattee

**==nnoo ddaattaa

MMooddiiffiieerr 00==nnoott aalllloowweedd 11==aalllloowweedd 99==nnoott aapppplliiccaabbllee

PPTTPP EEddiitt RRaattiioonnaallee

When 88342 is paired with 17311 a .59 modifier should be added to 88342

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Where do you find the NCCI Edits?

Scroll to bottom

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html


NCCI Web Page: col 1/col 2 edits

Scroll to bottom of web page, to “Related Links” Click and download the below highlighted column 1/column 2 edits


Example 1: Correct Coding


Correct answer: 17311 – Mohs surgery, first stage 88342.59 – Immunohistochemistry,


1 2

3 4


Example 2

1 2

3 4


Slides from each block are separately stained with: §  H & E §  Melan-A §  MITF

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Answer 2

Slides from each block are stained with: §  H & E §  Melan-A (MART-1) §  MITF

Answer: 17311 – Mohs surgery, first stage 88342.59 – IHC, one specimen, one stain 88341 – IHC, one specimen, second stain

Is this correct?

1 2

3 4


Answer 2: Correct

1 2

3 4


Slides from each block are stained with: §  H & E §  Melan-A §  MITF Answer: 17311 – Mohs surgery, first stage 88342.59 – IHC, one specimen, one stain 88341 – IHC, one specimen, second stain

Why no modifier on 88341?


NCCI column 1/column 2 edits

CCoolluummnn 11

CCoolluummnn 22

** == IInn eexxiisstteennccee pprriioorr ttoo 11999966

EEffffeeccttiivvee DDaattee

DDeelleettiioonn DDaattee

**==nnoo ddaattaa

MMooddiiffiieerr 00==nnoott aalllloowweedd

11==aalllloowweedd 99==nnoott

aapppplliiccaabbllee PPTTPP EEddiitt RRaattiioonnaallee

88341 is not listed in column 2. Therefore, no modifier is needed.

1731188342 20070101* 1


1731188344 20150101* 1



Example 3

First stage of Mohs, spindle cell SCC, temple o  One contiguous tissue layer excised o  Bisected o  Each half placed upon a separate block, separate slides made

1 2 Slides from each block stained with: §  H&E §  Pancytokeratin AE1/AE3

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Answer 3

1 2

Spindle cell SCC Slides from each block stained with: §  H&E §  Pancytokeratin AE1/AE3

Answer: 17311 – Mohs surgery, first stage 88342.59 – antibody cocktail stain: single stain, individual antibodies not distinguishable .59 modifier appended as per NCCI col 1/col 2


Example 4: Mohs surgery, 2 stages

1 2

3 4

Two stages of Mohs, lentigo maligna, cheek o  First stage: one tissue layer, quadrisected, each piece placed upon a block o  Second stage: two separate tissues excised, identified, and processed

individually as two separate blocks



Answer 4: Mohs surgery, 2 stages


First stage: 17311 – Mohs surgery, first stage 88342.59 – IHC, one specimen, one stain Second stage: 17312 – Mohs surgery, first stage 88342 – IHC, specimen 1 88342 – IHC, specimen 2

1 2

3 4

1

2


Answer 4: Mohs surgery, 2 stages


1 2

3 4

1

2

First stage: 17311 – Mohs surgery, first stage 88342.59 – IHC, one specimen, one stain Second stage: 17312 – Mohs surgery, first stage 88342 – IHC, specimen 1 88342 – IHC, specimen 2

Coding explanation: 1.  Stage 2 has two separately identified,

discontiguous specimens; therefore, each qualifies for an individual IHC stain code

2.  There is no NCCI edit with 17312, so no .59

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Example 5

Formalin fixed biopsy tissue of a melanoma o  Tissue stained with: o  H&E o  Pan melanoma and Ki-67 multiplex IHC stain

Coding: 88305 – Histopathology, H&E 88344 – IHC, multiplex stain

No .59 modifier required, as per NCCI edits


Documentation Requirements

•  Medicare Administrative Contractor Local Coverage Determinations (LCDs) – Mohs surgery –  “Special Histochemical Stains and

Immunohistochemical Stains” •  Medically Unlikely Edits (MUEs)


LCD: Special Histochemical Stains and Immunohistochemical Stains

•  Pertains to all instances of immunohistochemical staining: does not differentiate between formalin fixed, paraffin embedded tissue and Mohs surgical specimens

•  MACs with above Local Coverage Determination (LCD): – Noridian – First Coast – CGS


LCD: Immunohistochemical Stains

•  Local Coverage Determination (LCD) is geared toward pathology, rather than Mohs, but it does not exclude Mohs

•  Documentation requirements: –  Document why additional (IHC) testing was done –  Document medical necessity, results of stains, and how

information was used –  “It is well recognized that most skin lesions are diagnosed with

routine H&E slides. That is the case for most melanomas and other pigmented lesions as well.”

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Mohs, IHC and Biopsy MUEs

HCPCS/CPT Code

Practitioner Services MUE Values MUE Adjudication Indicator MUE Rationale

11100 1 22 Date of Service Edit: Policy Code Descriptor /

CPT Instruction

11101 6 33 Date of Service Edit: Clinical Clinical: Data



17313 3 33 Date of Service Edit: Clinical Clinical: CMS Workgroup



88342 3 3 Date of Service Edit: Clinical Nature of Service/Procedure

88344 1 1 Line Edit Nature of Service/Procedure


AAD can help with Coding Questions?

General questions - [email protected]

Peggy Eiden - [email protected]

Ana Maria Bustos - [email protected]

Cynthia Stewart - [email protected]

Faith McNicholas - [email protected]


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