Medicare Patient: 67 years old
Date of Service: 1-1-15
Clinical Info/Hx: Smoker with persistent cough.
Gross Description: Received in formalin, labeled left lower lobe (LLL) core biopsy, are multiple irregular to roughly cylindrical, tan-white, focally red soft tissues, measuring up to 1.3 x 0.6 x 0.1 cm in greatest dimension. Entirely submitted in 1 cassette.
Final Microscopic Diagnosis: Non-small cell lung carcinoma (NSCLC) - Poorly differentiated squamous cell. The carcinoma cells are positive for CK 5/6 cocktail, CK 7, p63, and show focal TTF-1staining. The carcinoma cells are negative for Napsin A.
What are the appropriate CPT, CPT II, ICD-9 and ICD-10 codes for this scenario?
Lung biopsy is a listed specimen in Current Procedural Terminology (CPT®) as 88305. Report documentation indicates that the multiple core samples were from a single anatomic site (LLL); therefore, only one unit of 88305 is assigned.
A total of five Immunohistochemical (IHC) stains were interpreted. The first IHC stain (CK5/6 cocktail) is coded as 88342, and the additional four IHC stains (CK7, p63, TTF1 and Napsin A) are coded as individual units of 88341, for a total of four units.
Please note: Since the CK 5/6 is reported as a cocktail stain, where two antibodies are stained on the same slide during a single staining procedure, and the antibodies are not separately identifiable, only one unit is appropriate. Refer to the parenthetical statements below the IHC code descriptors in the CPT Coding Manual for additional information on cocktail versus multiplex stains.
Since the CPT, diagnosis code and patient age meets the requirements for PQRS measure #395, the report should be reviewed to determine if the requisite documentation was identified in order to assign the appropriate PQRS code. The report documents the NSCLC classification of “poorly differentiated squamous cell carcinoma,” therefore, it is appropriate to assign CPT II code G9418.
2015 CPT/CPT II Code Definitions:
Malignant neoplasm of lung. Left lower lobe describes the anatomic site of the malignancy, but there is no code for laterality in ICD-9. Alpha Neoplasm table – lung – lower lobe 162.5. The ICD-9 code is broken down as follows:
- 162 is the primary description of malignant neoplasm for trachea, bronchus and lung
- 4th digit of 5 defines the anatomic site as lower lobe
Malignant neoplasm of lung. Left lower lobe describes the anatomic site of the malignancy and laterality in ICD-10. Alpha Neoplasm table – lung – lower lobe C34.3_. The ICD-10 code is broken down as follows:
- C34.3_ is the primary description of malignant neoplasm, lung - lower lobe
- 4th digit of 3 defines the anatomic site as lower lobe
- 5th digit of 2 defines laterality as left