Does 88342 require prior authorization?

No, 88342 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 88342?

Medicare facility rate: $110.22. Non-facility rate: $110.22. Work RVU: 0.68.

Verity

`88342`

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.68

Facility

$110.22

Non-Facility

$110.22

Documentation Required

Claims for ER, PR, or HER2 IHC must include the CPT code, the specimen identifier, and the unit of service (UOS) for each separately identifiable specimen.
For morphometric analysis, the claim must specify the appropriate CPT (88360 for manual or 88361 for computer-assisted) and the corresponding UOS.
To report a dMMR service, submit CPT code 88342 (one unit) and CPT code 88341 (three units) as indicated.
To report an MSI service, submit CPT code 81301 (one unit).

Key Coverage Criteria

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.
Testing for microsatellite instability-high (MSI-H) or mismatch repair deficiency (dMMR) is reasonable and necessary for patients with unresectable or metastatic solid tumors when MSI/dMMR testing has not previously been performed on the patient’s tumor sample.
dMMR testing by immunohistochemistry (IHC) is an acceptable method for establishing dMMR status for patients with unresectable or metastatic solid tumors.
MSI testing by PCR is an acceptable method for establishing MSI status for patients with unresectable or metastatic solid tumors.
A multi-gene next-generation sequencing (NGS) panel that includes MSI microsatellite loci and the MLH1, MSH2, MSH6 and PMS2 genes is an acceptable and reasonable method for MSI/dMMR testing.

20 Active Policies

A55136 — Billing and Coding: Lab: Immunohistochemistry (IHC) Indications for Breast Pathology

J05

A57733 — Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical Stains

J05

L36805 — Lab: Special Histochemical Stains and Immunohistochemical Stains

J05

A56103 — Billing and Coding: MolDX: Microsatellite Instability-High (MSI-H) and Mismatch Repair Deficient (dMMR) Biomarker for Patients with Unresectable or Metastatic Solid Tumors

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88342