Wednesday, March 20, 2019

How CMS Handles the CPT Block-Retrieval and Laser Dissection Codes That Precede Tumor Genomics

This past week, someone asked how the CPT codes for retrieving a paraffin block (88363) and laser dissection of a block (88380) differed, and how Medicare handled them.

It was a more interesting question than I expected.  It's also interesting to compare how Medicare handles 88363 for pulling a block (it pays it) versus another CPT code, 0502T, which is for data preparation and transmission of a cardiac CT scan for advanced digital fraction flow reserve analysis (via the Silicon Valley cardiac company HeartFlow; see 0501T-0504T.  More here.)

  • 88363   Examination and selection of retrieved archival (ie, previously diagnosed) tissue(s) for molecular analysis (eg, KRAS mutational analysis)

This code is billable global-only (not as professional and technical component).  In an independent lab, Medicare pays $24.15.   If the physician doing this is in a facility, Medicare pays him/her $20.54.  The code dates to 2011.  It has a very long RUC rationale (AMA subscription database RBRVS DataManager.)  The RUC surveyed it and noted it had lower value than an intraoperative consult (frozen section).  They ended up with .37 Work RVUs for 17 minutes of not super intense MD time.  There are six minutes for a lab technician, and 6 minutes of capital equipment microscope use for 19 cents.

The code was used 18,494 times in Part B in 2012, rising to 26,343 times in Part B in 2017 (about $600,000).  (Added:  2018 Part B use was 29,011 times for $637,509).  93% of the time it was billed by a pathologist, but 6% of the time directly by a lab (e.g. the lab's NPI).   62% of locations were hospital (so only $20.54 was paid), 16% office, 9% independent lab (where $24.15 is paid) .  The main diagnosis codes were breast (20%), followed by lung, prostate, and colon (at 16%, 10%, 7%). 

The physician personal work vignette is:  After verifying that the patient has tissue samples in the pathology archives, the pathologist reviews the reports and examines the slides and blocks from the relevant specimens to determine which has the richest and most representative area of non-necrotic tumor for [e.g.] KRAS analysis, such to be sent to an appropriate reference testing laboratory.  The service does not include the molecular diagnostic interpretation or microdissection.  The physician (pathologist) will document the review of the pertinent pathology reports and slides and selection of the appropriate material for submission.

There don't seem to be any LCDs or Articles about 88363.

Hospital Outpatient Handling of 88363 APC/OPPS

88363 has status indicator Q1, and APC placement 5731 ($17).*   Q1 means it is payable unless it is billed together with a status code S, T, V, or X... in which case it is bundled and no separate payment.  I would imagine there could be circumstances where pulling the block was the only service for that patient that day.

Why Did I Bother?  88363 for Pulling a Block vs 0502T for Pulling Radiology Case

The interesting thing is to compare the handling of 88363 to 0502T, the latter for pulling imaging information from an archive and transmitting it to an outside analysis center.   0502T has status code "N" meaning never paid in the hospital outpatient setting.  It's bundled with any underlying service, even if not on the same claim.  

Score in the Outpatient APC Arena: Pathologists 1, Radiologists 0.

In Part B, it looks like 0502T is "contractor priced," not Status N, so it could be payable in an independent facility.  The code is too new to have any publicly released data on utilization (on claims paid).

  • 88380   Microdissection (ie, sample preparation of microscopically identified target); laser capture

This code can be broken into global, professional, and technical components.  In an independent setting, it pays $136.   For a physician working in an institution, he gets $57.  The code dates to 2015.  It's timed for 33 minutes of physician work.  While under review, the inputs change, rising to as many as 11 slides.  They're cut, but not stained. Technician time is 72 minutes.  Supplies and capital costs are minor (slides, alcohol, microtome).  But a capital equipment Veritas microdissector is $195,000 with a 7 year life, is used for 37 minutes for $22.

Don't look for much use of this code.  It had 163 uses in 2017, down from 254 uses in 2014.  That's a paltry total of $23,000.  64% of uses were in an independent laboratory.

The physician personal work vignette is:  A review of a serial slides shows tiny clusters of cancer cells interspersed among numerous lymphocytes. The tumor and normal cells are almost inseparable. All the blank slides are stained with a DNA-compatible stain. The pathologist performs laser capture microdissection of multiple high power fields to obtain an adequate number of cells for DNA sequencing. Typically over 2,000 cells are microdissected for each assay.

  • 88381  Microdissection (ie, sample preparation of microscopically identified target); manual dissection

This code is for manual dissection, e.g. not using a laser.  It actually pays somewhat more, $156.

The work vignette shows that the pathologist circles the tumor and a technologist dissects it:  Following comparison with adjacent stained sections from the same tissue block, areas of adenocarcinoma tumor cells in the background of normal lung cellular parenchyma and inflammation are microscopically identified and marked by the pathologist. The pathologist counts a representative sample of tumor and non-neoplastic cells in the circled area to estimate the proportion of tumor cells in the microdissected area. The tumor cells are manually obtained from all the marked areas for DNA extraction (by the technologist) and analysis for EGFR mutations.

Only 20, not 33, minutes of MD work are used.  But now the technician work rises to 106 minutes from 72 minutes in 88380.

For 88381, utilization was 19,222 in CY2017 in Part B.  That's about $3M.  73% of services are in an independent lab, 27% in physician office.

MAC Policy for 88380, 88381

Only one MAC showed up on a keyword based article search, FCSO.  It remarks in LCD L34510:  "Any procedures required prior to cell lysis (e.g., microdissection [CPT codes 88380 and 88381]) should be reported separately and utilization must be clearly supported based on the application and clinical utility. Such claims may be subject to prepayment medical review."

While one could argue a laser isn't always necessary, the work of pulling a block and cutting unstained slides in order to do FFPE NGS surely is always necessary, so use of code 88381 should be pretty safe, at least to my reading.

Hospital Outpatient Handling of 88380, 88381

Easy - zilch.

Both 88380, 88381 are bundled services and N = Never paid in hospital outpatient settings (to the hospital's APC).  Whereas 88363, pulling a paraffin block, is $17 for the hospital to usually send the block to an outside reference lab, 88380/81 for laser dissection are presumably paired to local services for which the hospital gets paid (e.g. 81445, DNA sequencing of 5-50 tumor genes, etc).


I've heard a CMS MAC medical director say that he/she didn't usually expect to say the laser dissection code billed (88380) because usually you can just circle the tumor and pick blocks that way for unstained slides for sequencing.   Well, yes, fair enough, but manual dissection actually pays more than laser dissection - $156 (88381) vs $136 (88380), so you are just chasing people away from a $136 code and into a $156 code.

Hospital outpatient summary.   In this article, we've reviewed four codes - 0502T and 88363 for pulling things (imaging and blocks, respectively), and  88380/88381 for dissection.  Of the four codes, only 88363 for "pulling blocks from an archive" has payable status in the APC setting.

   0502T - Radiology data pull and send - no APC payment.
   88363 - Pull slides from archive - APC 5731 for $17 (but can get bundled to certain other procedures if on the same day)
   88380 - Laser microdissection - no APC payment
   88381 - Manual microdissection - no APC payment

Part B Utilization Summary (2017)

  0502T - Radiology data pull; No data available yet.
  88363 - Pull slides from archive - ~26,000 uses for $600,000.
  88380 - Laser microdissection -  ~160 uses for $23,000.
  88381 - Manual microdissection - ~19,000 uses for $3M.

Note: This article reflects my best knowledge working from AMA, CMS databases, but you need to make any coding research and decisions for your own lab.

* APC 5731 is "Level 1 Minor Procedures."