Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (88368-59, 88369, 88377 and G0452) 
provided on December 2, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that these services are supported in the medical 
record. The Plan denied your request. The Plan says these codes are included in the payment for code 81342. 
The Plan states although modifiers were used in this case, the records provided do not support that these 
modifiers were used appropriately.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 88368-59 is morphometric analysis, in situ hybridization 
(quantitative or semi-quantitative), manual, per specimen; initial single probe stain procedure. The definition of 
code 88369 is morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per 
specimen; each additional single probe stain procedure (List separately in addition to code for primary 
procedure). The definition of code 88377 is morphometric analysis, in situ hybridization (quantitative or semi-
quantitative), manual, per specimen; each multiplex probe stain procedure. The definition of code G0452 is 
molecular pathology procedure; physician interpretation and report. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the laboratory services. Our reviewer found for Current 
Procedural Terminology (CPT) code 88368-59 the documentation submitted was reviewed and does not meet 
criteria. The laboratory report includes insufficient documentation to verify separate results reported for 
different species or strains that are described by the same CPT code to support appropriate use of modifier -59 
distinct procedural service from CPT 81342.  
 
For CPT 88369, the documentation submitted was reviewed and does not meet criteria. The laboratory report 
includes insufficient documentation to verify separate results reported for different species or strains that are 
described by the same CPT code to support appropriate use of modifier -59 distinct procedural service from 
CPT 81342.  
 
For CPT 88377, the documentation submitted was reviewed and does not meet criteria. The laboratory report 
includes insufficient documentation to verify separate results reported for different species or strains that are 
described by the same CPT code to support appropriate use of modifier -59 distinct procedural service from 
CPT 81342.  
 
For code G0452, the documentation submitted was reviewed and does not meet criteria. G0452 is used to 
report a medically necessary interpretation and written report of a molecular pathology test, above and beyond 
the report of laboratory results. In this case, the laboratory report describes a laboratory report results, and 
interpretation and written report was not found in medical record submitted. The laboratory result documents 
two separate medical doctors, and therefore, unable to verify a written interpretation and report. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (88368-59, 88369, 88377 and G0452) provided on December 
2, 2022.