CAP Convinces United Healthcare To Correct an IHC Payment Policy

Following extensive advocacy and engagement by the College of American Pathologists (CAP), the nation’s largest insurer United Healthcare has changed its policy limiting payment for AMA CPT code 88342 for immunohistochemistry (IHC). The insurer will reverse its policy that lowered the number of units pathologists could bill for the code 88342 to one effective January 1, 2014. Based on its understanding of 2014 CPT code changes, United Healthcare’s policy was to allow only one unit of CPT code 88342 per patient, per day, unless claims were submitted with modifiers 59 or 91. The CAP alerted United Healthcare to the problem earlier in 2014 and has since worked to provide more information to the insurer and its payment policy leadership team on the correct interpretation and application of the 2014 AMA CPT description for the code. AMA CPT states 88342 is billed for each separately identifiable antibody per block, cytologic preparation, or hematologic smear; first separately identifiable antibody per slide. United affirmed that it has increased the number of units, or its maximum frequency per day (MFD), for 88342 to 13 in its systems and on its website for all claims processed beginning May 18. Claims adjudicated on or after May 18 do not require modifier 59 to indicate greater than one unit, as medically necessary. United is working on the process for handling denial of units of 88342 that exceeded one processed before May 1, 2014.