CPT code 88363 is for the Examination and selection of retrieved archival (ie, previously diagnosed) tissue(s) for molecular analysis (eg, KRAS mutational analysis).
This CPT code should be reported IF the treating physician requests a molecular test on tissue from a case that has already been resulted and that the pathologist has released a report to the patients’ medical record.
In this setting the term “archive” has nothing to do with Medicare’s definition for an “archive specimen”. For this code “archival” refers to the original specimen being released by the pathologist and the slides placed in queue for storage.
This is a global service and the work done must be reported by a pathologist. Often the best way to report this service is to create an addendum to the original pathology report. The below is a template and should be sufficient documentation to support using CPT 88363 for this service:
A request for [name of molecular analysis] was received [date] for patient [name] from
Dr. [ordering physician]. The test is to be performed on tissue from case [accession number (date)]. The case report, slides, and blocks for the cited accession were retrieved
from archives. The pathologist whose signature appears below reviewed the original
pathology report, examined candidate H&E slides, and selected the block ([#label])
appropriate to the specifications of the ordered molecular analysis. Unstained slides
([count]) were prepared and forwarded to [name of reference lab] where the subject
molecular test will be performed. An addendum report will be issued when the results of
this molecular test are available.
* * * Electronically Signed * * *
[name of pathologist]