CMS has determined that it is inappropriate to use CPT code 88358 for the automated quantitative image analysis of tumors. Earlier this year CMS initiated a Correct Coding Initiative (CCI) edit that prevents the simultaneous coding of CPT 88342 with CPT 88358. This audit has only affected those groups that have been billing for both preparing the immunostains and performing the technical portion of the image analysis. Most pathologists have not been affected because they are billing only for the professional portion of the automated quantitative image analysis.

CMS is currently working with the College of American Pathologists to develop a new code for this procedure and a new Medicare allowable that will become available January 1, 2004. The new allowable is almost certainly going to be less than the current professional and technical allowables for CPT 88358.

Most pathologists have continued to bill for this procedure using CPT code 88358 because this information has not been widely disseminated. This code is still allowable for non-automated DNA ploidy studies so it is currently being paid when billed without CPT 88342. However, CMS has made it clear that this is the incorrect code for automated quantitative image analysis. Pathologists who continue to use this code for image analysis should be aware that Medicare may ask for refund of money paid for this code, although that does not seem likely. It is possible that Medicare may only ask for a return of any money paid in excess for the current allowable for CPT 88358 as compared to the allowable for the new code. Finally, it is possible that there will be no further action on the part of Medicare to recoup any funds whatsoever.

Each pathologist or pathology group should determine whether or not they are going to continue to use a code that Medicare has clearly stated is incorrect for this procedure. It might be prudent to speak with your image analysis vendor or the laboratory providing your technical service to help you make this determination.