ICD 10 Coding Alert

Don’t try to use surgeons’ lay terms on claims.

We’ve all come across terms like “mass” and “lesion” when evaluating surgeons’ specimen notes.

Make sure you get specific when making procedure coding choices; otherwise, you risk some major money.

See the Scenario

The surgeon identifies the case as a debulking procedure for a patient with recurrent ovarian cancer following a total hysterectomy. He submits the following tissue, which the pathologist processes for pathology examination:

• Specimen A: Cassettes 1-3: 5.3 x 4.8 x 4.4 cm pelvic mass attached to the lesser pelvic sidewall and the rectosigmoid
• Specimen B: Cassette 4: 6.3 cm liver lesion
• Specimen C: Cassettes 5-8: Sigmoid colon resection for partial obstruction.

Findings: Upon examination of each of the three specimens, the pathologist determines that the pelvic mass, liver lesion, and colon obstructive mass are all metastatic serous adenocarcinoma consistent with the primary ovarian cancer.

Nail the Diagnosis Coding

If you take the initial specimen descriptors at face value for determining the diagnosis in this case, you would be wrong. Plus, missing the correct diagnosis could cost your pathologist significant pay, as you’ll read about in the next section.

The diagnosis codes based on the description of the submitted specimens might look something like this, but they aren’t the appropriate codes for this case:

• Pelvic mass (R19.05, Periumbilic swelling, mass or lump)
• Liver lesion (K76.89, Other specified diseases of liver)
• Colon obstruction (K56.609, Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction).

Consider surgical procedure: Your first clue to appropriate diagnosis coding is that the surgeon submits the pathology specimens from a debulking procedure to treat ovarian cancer. A likely surgical procedure code would be 58957 (Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed). That means you know you’ll need to code the ovarian cancer, which is C56.9 (Malignant neoplasm of unspecified ovary).

Code from findings: Rather than assigning the diagnosis code based on the initial specimen description, you should look to the findings from the pathology exam to assign the diagnosis. “Accurate diagnosis coding means waiting for the pathology report and basing your code selection on that, as the final diagnosis,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, California.

Here are the appropriate diagnosis codes for the specimens in this case, which the pathologist identifies as ovarian metastatic serous adenocarcinoma:

• Specimen A: C78.6 (Secondary malignant neoplasm of retroperitoneum and peritoneum)
• Specimen B: C78.7 (Secondary malignant neoplasm of liver)
• Specimen C: C78.5 (Secondary malignant neoplasm of large intestine and rectum).

Code sequence: To correctly code the diagnosis in this case, you need to understand ICD-10 rules for sequencing primary and secondary (metastatic) neoplasm codes. The rule is that if the encounter is to treat the primary cancer, you should code that first. If the procedure is directed toward only the metastatic site, you should code that site first, followed by the primary cancer diagnosis.

Because the surgeon performed the procedure (and submitted the specimens) to treat the metastatic ovarian cancer, you should code first the ovarian cancer using C56.9, followed by the codes for metastatic (secondary) cancer based on the site.

Look to Procedure Codes

Now that you know the diagnosis codes for the specimens, you can assign the appropriate surgical pathology procedure code.

Here’s why: CPT^® assigns different surgical pathology specimens to different codes based on the level of work the pathologist must perform to evaluate the “typical” specimen of a specific tissue type. The same type of tissue may take a different code based on whether the pathologist examines it for a neoplasm — which takes more work — or for a tumor, which generally takes less work.

For instance: A partial colon resection evaluated for a reason other than neoplasm reports to 88307 (Level V - Surgical pathology, gross and microscopic examination… Colon, segmental resection, other than for tumor…), while a partial colon resection evaluated for tumor reports to 88309 (Level VI - Surgical pathology, gross and microscopic examination … Colon, segmental resection for tumor…).

In this case, the pathologist receives and separately evaluates three distinct specimens. “You should list the appropriate code for each unique specimen the pathologist examines and diagnoses,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Arkansas.

That means you should not bundle the tissue in this case into a single “debulking” specimen, but should instead report one procedure code for each specimen as received and examined. Here’s the appropriate codes for the case:

• Specimen A: The code for this specimen is 88307. Although “pelvic mass” is not a listed specimen, coding convention equates this specimen with a similar specimen such as the mediastinum mass, which CPT^® lists as 88307.
• Specimen B: This specimen also takes 88307 (… Liver, partial resection)
• Specimen C: Because the pathologist examines this colon specimen for tumor, you should list the service as 88309.

Bottom line: If you had reported Specimen C as 88307 instead of 88309, that makes the difference between your pathologist getting paid $290.31 instead of $441.75 for the service (based on Medicare Physician Fee Schedule national global facility amount, conversion factor 34.8931).