88312
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.53
Facility
$109.55
Non-Facility
$109.55
Documentation Required
- Claims for IHC ER/PR/HER2 must include the appropriate CPT code(s) and unit(s) of service as specified in the policy.
- Each billing party (professional and/or technical) is responsible for documenting and justifying the medical necessity of services billed.
- Claims for ER, PR, and HER2 IHC must be submitted using the specified CPT codes and unit-of-service values (see frequency section) and be supported by documentation of medical necessity.
- Parties submitting professional and/or technical components are each responsible for ensuring and documenting the medical necessity of services billed.
Key Coverage Criteria
- Immunohistochemical (IHC) testing for estrogen receptor (ER), progesterone receptor (PR), and HER2/neu is covered for patients with primary invasive breast cancer.
- IHC testing for ER, PR, and HER2/neu is covered for patients with recurrent or metastatic breast cancer.
- IHC testing for estrogen receptor (ER) is covered for patients with primary invasive breast cancer and for recurrent or metastatic breast cancer.
- IHC testing for progesterone receptor (PR) is covered for patients with primary invasive breast cancer and for recurrent or metastatic breast cancer.
- IHC testing for Her-2/neu (HER2) is covered for patients with primary invasive breast cancer and for recurrent or metastatic breast cancer.
- IHC testing for estrogen receptor (ER) is covered for patients with primary invasive breast cancer.
15 Active Policies
A57733 — Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical Stains
J05
L36805 — Lab: Special Histochemical Stains and Immunohistochemical Stains
J05
A57614 — Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical Stains
A59295 — Billing and Coding: Special Histochemical Stains and Immunohistochemical Stains
A60178
Related Codes
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