Clinical Data: Female Medicare patient. Breast Cancer Primary - currently receiving treatment.
Gross Description: Received in formalin labeled “Liver Needle Core Biopsy,” is a portion of pink tan tissue measuring 1.1 x 0.2 cm. The core is submitted in 1 cassette.
Microscopic Diagnosis: Liver biopsy - Benign liver tissue, negative for carcinoma. No evidence of metastatic breast cancer.
CPT: 88307 ICD-9: 174.9
Question: Does this case require reporting the Physician Quality Reporting System (PQRS) Breast Measure #99?
Answer: Yes, based on the CPT/ICD-9 coding combination of 88307 and 174.9 this liver biopsy qualifies for the PQRS breast measure, and should be reported with Quality Data Code (QDC) 3250F.
Rationale: First, it is important to understand that PQRS eligibility is based on established CPT and ICD-9 coding combination criteria. Any case with CPT code 88307 or 88309 billed in conjunction with a primary breast neoplasm ICD-9 code (174.0-174.9, 175.0 or 175.9) will be included in Medicare’s “Denominator” (all eligible cases that meet the PQRS eligibility criteria CPT and ICD9) for breast measure #99.
It is also important to recognize why the liver specimen is coded with a breast cancer diagnosis. Per the ICD-9-CM Coding Guidelines, definitive or confirmed diagnoses from a physician’s interpretation should be assigned as the primary diagnosis code when the final report is available at the time of coding. When a diagnosis has not been established, the code is based on the sign(s), symptom(s), or clinical history that prompted the treating physician to order the pathologic evaluation. In this scenario, a final diagnosis of benign tissue was rendered. Since a definitive diagnosis was not provided, and there is no ICD-9 code for “negative, normal, or benign,” the primary breast cancer documented in the clinical data is coded as 174.9 (Malignant neoplasm of female breast, unspecified). Therefore, the assignment of 88307 (Liver, biopsy – needle/wedge), in combination with 174.9, qualifies this specimen for the breast measure.
Finally, the appropriate QDC must be assigned in order for Medicare to also include in the “Numerator” (all cases meeting the PQRS eligibility criteria CPT & ICD-9 that are also reported with a QDC). There are four QDC options for measure #99:
- 3260F: (pT, pN and histologic grade ARE documented in path report)
- 3260F-1P: (Medical reason(s) documented for NOT including pT, pN and histologic grade in path report (e.g re-excision without residual tumor)
- 3260F-8P: (pT, pN and histologic grade were NOT documented in path report, Reason not specified)
- 3250F: (Patient not eligible for this measure because specimen(s) are not primary breast tissue (e.g. liver, lung metastasis) report: Specimen site other than anatomic location of primary tumor).
In preparation for ICD-10 coding, the following diagnosis codes are listed for the 2014 CMS PQRS Measure #99 (breast cancer). The chart below will provide the coding differences between the ICD-9-CM and the ICD-10-CM assignment.
Click here to access the 2014 CMS PQRS Measure Specification Manual
American Medical Association. CPT Manual 2014
American Medical Association. ICD-9-CM Manual 2012
Optum. Draft ICD-10-CM Manual 2014
CMS. PQRS Measure Specifications Manual for Claims and Registry Reporting of Individual Measures 2014
This commentary is a summary prepared by McKesson’s Business Performance Services division and highlights certain changes, not all changes, in 2014 CPT® codes relating to the specialty of pathology. This commentary does not supplant the American Medical Association’s current listing of CPT® codes, its documentation in the annual CPT Changes publications, and other related publications from American Medical Association, which are the authoritative source for information about CPT® codes. Please refer to your 2014 CPT® Code Book, annual CPT® Changes publication, HCPCS Book and Payer Bulletins for additional information, including additions, deletions, changes and interpretations that may not be reflected in this document.
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