New codes 88387 and 88388 for 2010 were established to report the sterile macroscopic dissection performed prior to ancillary diagnostic testing applicable to molecular studies.
88387 - Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies (e.g., nucleic acid-based molecular studies); each tissue preparation (e.g., a single lymph node)
(Do not report 88387 for tissue preparation for microbiologic cultures or flow cytometric studies)
(Do not report 88387 in conjunction with 88388, 88329-88334)
+88388 - ...........in conjunction with a touch imprint, intraoperative consultation, or frozen section, each tissue preparation (e.g., a single lymph node) (List separately in addition to code for primary procedure)
(Use 88388 in conjunction with 88329-88334)
(Do not report 88387 or 88388 for tissue preparation for microbiologic cultures or flow cytometric studies)
Following the code description and parenthetical instructions, code 88387 is reported when the pre-analytic work is performed outside the intra-operative or frozen section room. Code 88388 per CPT is designated as an “add-on” code and will be reported when the pre-analytic work is performed in conjunction with an intraoperative consultation for the specimen in question and reported with a code from the 88329-88334 range. Both codes are only to be reported for non- microscopic analytic studies (codes 83890-83913) and will not apply to pre-analytic work prepared on tissue for IHC -based tumor morphometry analysis, chemosensitivity assay, or other special study not involving DNA or RNA.
The medical report must include:
- The pre-analytic work that was performed
- Description of the examination
- Dissection that was performed
- Reference the precautions taken to avoid contamination
- Mention of the molecular analysis anticipated
- Example: “A sentinel node is received for complex macro exam and dissection. At a sterile workstation and with sterile equipment to avoid contamination a 2.5 node is identified in the fatty tissue and dissected. Thin sections are cut to submit for XXX testing, labeled and packed for shipping to XXX Lab. The remaining is frozen and submitted in one block. Frozen section is examined and findings are provided to the surgeon in the OR.”
Codes 88387 and 88388 are reported once for “each tissue preparation.” If two separately identified sentinel nodes are submitted and a separate prep performed on each for molecular testing, report 88387 or 88388 times two.
As 88387 and 88388 cannot be reported for microbiologic cultures or flow cytometric studies, the National Correct Coding Initiative (NCCI) edit bundles 88387 and 88388 with flow cytometry codes 88182, 88184, 88185 and 88187-88189 and code 88387 will bundle with codes 88329-88334 as per CPT, code 88387 cannot be reported with the intraoperative codes.
If you have any questions or additional comments regarding this information, please feel free to contact Tom Scheanwald or Janice Toczynski, CPC at (800) 288-8325 or by e-mail:
Tom Scheanwald – email@example.com
Jan Toczynski – firstname.lastname@example.org