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Still Confused on Coding Special Stains and IHC?
The American Medical Association (AMA) published the new 2012 CPT® codes, which include significant updates to coding for special stains. This update provides clear instructions of how to assign the units of service for Medicare/Medicaid patients versus commercially insured patients. In addition, the Centers for Medicare & Medicaid Services (CMS) via the National Correct Coding Initiative (NCCI) publication for Jan. 1, 2012, make a significant alteration to the immunohistochemical (IHC) stain coding instructions.
Special Stain Updates for 2012
The CPT® 88312-88319 code family has additional parenthetical instructions following the code set that will assist and likely dispel any confusion on assigning units of service for these codes. That statement says:
Report one unit of 8831X for each special stain, on each surgical pathology block, cytologic specimen, or hematologic smear.
This additional AMA instruction coincides and supports the guidance given by the NCCI in October 2009. In that NCCI publication, CMS states to assign the unit of service for special stains based on the surgical pathology block, not the specimen. The update from the AMA for 2012 finally confirms this as the correct method of assigning units of service, regardless of payer. CMS NCCI 2009 edit narratives were updated in the Jan. 1, 2012, edition and state:
The unit of service for special stains (CPT codes 88312-88313) is each stain. If it is medically reasonable and necessary to perform the same stain on more than one specimen or more than one block of tissue from the same specimen, additional units of service may be reported for the additional specimen(s) or block(s). Physicians should not report more than one unit of service for a stain performed on a single tissue block. For example, it is common practice to cut multiple levels from a tissue block and stain each level with the same stain. The multiple levels from the same block of tissue stained with the same stain should not be reported as additional units of service. Only one unit of service should be reported for the stains on multiple levels from the single tissue block. Additionally, controls performed with the special stains should not be reported as separate unit of service for the stain.
For cytology specimens from a single anatomic site only one unit of service may be reported for each special stain regardless of the number of slides from that site stained with the special stain.
For hematology smears only one unit of service may be reported for each special stain regardless of the number of smears from an anatomic site stained with the special stain. For example, if multiple smears of peripheral blood are stained with an iron stain, only one unit of service may be reported. Similarly, if three smears from a bone marrow aspirate are stained with an acid fast stain, only one unit of service may be reported. Smears from peripheral blood, one iliac crest, and contralateral iliac crest are from three separate anatomic sites.
Clarification on the IHC Staining Guidelines from CMS and AMA
The unit of service for the IHC codes 88342, 88360 and 88361 is “per antibody.” The AMA has not made any updates to the 2012 CPT® code book for these codes. However, in the October 2010 CPT Assistant®, the AMA clearly provides instruction that states the unit of service of IHC staining is “per antibody” regardless of the number of blocks involved with the individual specimen.
CMS via the NCCI update for Jan. 1, 2012, confirms that the CMS policy aligns with this AMA concept and goes even further with restrictions for Medicare/Medicaid patients. They limit the unit of service to “each antibody(s) stain (procedure), per specimen, not just the stain itself and further limits units of service when ‘IHC cocktail’ stains are involved.” Cocktail stains are those that contain multiple different antibodies with that one single staining procedure that stain a different color but are interpreted all within that one single staining procedure. The 2012 NCCI Coding Manual provides this statement:
The unit of service for immunohistochemistry (CPT® codes 88342, 88360, 88361) is each antibody(s) stain (procedure) per specimen. If a single immunohistochemical stain (procedure) for one or more antibodies is performed on multiple blocks from a surgical specimen, multiple slides from a cytologic specimen, or multiple slides from a hematologic specimen, only one unit of service may be reported for each separate specimen. Physicians should not report more than one unit of service per specimen for an immunohistochemical antibody(s) stain (procedure) even if it contains multiple separately interpretable antibodies.
This new guidance reverses the special stain policy CMS issued in October 2009, which stated special stains should be billed per block and included codes 88342, 88360 and 88361. Therefore, from dates of service of Jan. 1, 2012, and forward, your unit of service for IHC stains is “one,” per separately identifiable specimen, per antibody, per stain/procedure, including multiple antibodies performed in a single cocktail stain procedure.
For example, a laboratory receives a single prostate specimen. That specimen has three blocks processed, A1, A2 and A3. The lab performs and the pathologist interprets a cocktail stain containing three separate antibodies within that one stained procedure on A1 and A3. In addition, a single IHC antibody CD20, different from the ones within the cocktail stain, is performed on A1, A2 and A3 blocks of that specimen. The pathologist reports a positive or negative result for each of the IHC antibodies interpreted on the blocks. The coding for the service is two units of 88342 (i.e., one unit for the cocktail stain and one unit for CD20) even though the pathologist performed the stains on multiple blocks with multiple antibodies interpreted in the cocktail stain.
AMA 2012 CPT®
NCCI Coding Manual, Chapter 10, Revision Jan. 1, 2012
Rick Oliver, JD, CHCO, CPC, MT(ASCP)
Compliance – Pathology and Laboratory
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