How To Use CPT Code 88361

CPT 88361 describes the procedure for morphometric analysis of tumor immunohistochemistry using computer-assisted technology. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 88361?

CPT 88361 can be used to describe the procedure for morphometric analysis of tumor immunohistochemistry using computer-assisted technology. This code is used when a single antibody stain is applied to a slide or slides prepared from a single patient specimen, such as tumor tissue. The stained slides are then processed using computer-assisted technology to count or estimate the number of stained cells. A qualified provider, typically a pathologist, evaluates the stained slides and interprets the results to provide a pathologic diagnosis.

2. Official Description

The official description of CPT code 88361 is: ‘Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; using computer-assisted technology.’

3. Procedure

1. The lab analyst prepares stained slides using a specialized stain called immunohistochemistry (IHC).
2. The lab analyst cuts and mounts the tissue onto slides and adds reagents to prepare the slides for the stain.
3. A single antibody stain is applied to the slides, targeting a specific antigen in the specimen.
4. The slides are processed using computer-assisted technology to count or estimate the number of stained cells.
5. A qualified provider, typically a pathologist, evaluates the stained slides and interprets the results to provide a pathologic diagnosis.

4. Qualifying circumstances

CPT 88361 is used for quantitative or semiquantitative immunohistochemistry stains performed on tumor tissue specimens. The procedure must involve the use of computer-assisted technology to analyze and enumerate the stained cells. It is typically performed by a pathologist or other qualified provider. This code should not be reported in conjunction with CPT codes 88341, 88342, or 88344 unless each procedure is for a different antibody.

5. When to use CPT code 88361

CPT code 88361 should be used when a single antibody stain is performed on tumor tissue specimens using computer-assisted technology for morphometric analysis. This code is appropriate for quantitative or semiquantitative evaluation of stained cells. If the procedure does not include a quantitative or semiquantitative evaluation, other codes in the range 88341 to 88344 should be used instead.

6. Documentation requirements

To support a claim for CPT 88361, the following documentation is required:

• Identification of the patient specimen and the specific antibody stain used
• Date of the procedure
• Results of the computer-assisted analysis, including quantitative or semiquantitative values
• Interpretation of the results by a qualified provider
• Pathologic diagnosis based on the stained slides

7. Billing guidelines

When billing for CPT 88361, ensure that the procedure involves a single antibody stain using computer-assisted technology for morphometric analysis. This code represents the global service, including both the technical work performed by the lab analyst and the professional work performed by the pathologist. If billing only for the technical component, append modifier TC. If billing only for the professional component, append modifier 26.

8. Historical information

CPT 88361 was added to the Current Procedural Terminology system on January 1, 2004. There have been historical changes to the code, including updates in 2005 and 2015.

9. Examples

1. A pathologist performs a quantitative immunohistochemistry stain on tumor tissue to determine the expression of Her-2/neu.
2. A lab analyst applies a semiquantitative immunohistochemistry stain on slides prepared from a patient’s tumor tissue, using computer-assisted technology to estimate the percentage of stained cells.
3. A pathologist performs a quantitative immunohistochemistry stain on tumor tissue to assess the expression of estrogen receptor and progesterone receptor.
4. A lab analyst applies a semiquantitative immunohistochemistry stain on slides prepared from a patient’s tumor tissue, using computer-assisted technology to generate a numerical score representing the range of stained cells.
5. A pathologist performs a quantitative immunohistochemistry stain on tumor tissue to evaluate the expression of a specific antigen relevant to the patient’s diagnosis.
6. A lab analyst applies a semiquantitative immunohistochemistry stain on slides prepared from a patient’s tumor tissue, using computer-assisted technology to provide a quantitative value indicating the percentage of stained cells.
7. A pathologist performs a quantitative immunohistochemistry stain on tumor tissue to determine the level of a specific protein associated with a particular disease.
8. A lab analyst applies a semiquantitative immunohistochemistry stain on slides prepared from a patient’s tumor tissue, using computer-assisted technology to generate a numerical score indicating the extent of stained cells.
9. A pathologist performs a quantitative immunohistochemistry stain on tumor tissue to assess the expression of a target antigen for personalized treatment planning.
10. A lab analyst applies a semiquantitative immunohistochemistry stain on slides prepared from a patient’s tumor tissue, using computer-assisted technology to estimate the proportion of stained cells for diagnostic purposes.