Part B Insider (Multispecialty) Coding Alert

Distinguish blocks, specimens for stains.

When your pathologist examines a liver resection case, you’ve got a lot to consider, from specimen type, to lymph node exams, to special stains, to final diagnosis. Mistakes can cost you — up to $138 if you make this one common error.

Let our experts help by breaking it down into four simple questions you need to ask and answer when you’re faced with your next liver case. Use the following example to learn these steps and make sure you capture all the pay you deserve.

Liver Case

Pre-Op Diagnosis: Liver mass, history of colorectal cancer

Procedure: Liver lesion right wedge resection

Pathology Report:

• Received right hepatic wedge resection measuring 7 cm x 9 cm x 3 cm
• Separately received hepatic lymph node resection containing seven nodes.
• Intraoperative report to surgeon on frozen section margin exams A, B, and C — clear.
• Identified three tumor foci and processed each block D, E, and F with hematoxylin and eosin (H&E) and Gomori’s one-step trichrome stain, as well as CK7, CK 20, CA-125, and CDX2, with findings consistent with metastatic colorectal cancer.
• Lymph nodes H&E stains, no tumor present

Final diagnosis: Hepatic Adenocarcinoma, metastatic from colorectal cancer

Step 1: Identify the Specimen

The pathology report identifies the specimen as a “right hepatic wedge resection.” If you look to CPT^®, you’ll see two possible code choices to describe the pathologist’s examination of this specimen:

• 88307 — Level V - Surgical pathology, gross and microscopic examination, Liver, biopsy - needle/wedge
• 88307 — … Liver, partial resection

From a coding perspective, identifying whether the specimen is a liver wedge biopsy/resection or liver partial resection is a bit of a distinction without a difference, because the payment code is the same (88307).

“The distinction may impact bundling of other tissues, however, so you should determine from the pathology report whether you’re dealing with a liver wedge resection or a partial resection,” says R.M. Stainton Jr., MD, president of Doctors- Anatomic Pathology Services in Jonesboro, Ark.

Wedge vs. partial: A partial liver resection is an anatomic excision that typically removes one or more lobes or segments. Physicians may instead opt for a non-anatomic, or wedge resection that spares as much parenchymal tissue as possible, typically in cases of metastatic cancer when the surgeon’s goal is to remove just the tumor lesions.

Lymph nodes: Although the CPT^® definition of either liver specimen doesn’t specifically state that you must bundle lymph nodes (as some listed specimens do), coding convention suggests that you should not separately report lymph nodes attached to a liver resection specimen. Attached nodes are more common in a partial anatomic resection than a wedge resection, possibly including hepatic, cystic or phrenic nodes.

Key: Regardless of the specimen type, you need documentation that the surgeon separately identified/submitted and the pathologist separately diagnosed lymph nodes to justify separately billing the service.

Do this: Because the case includes a separately-submitted regional lymph node resection, you should report the service as 88307 (…Lymph nodes, regional resection). You should not separately report each lymph node as seven units of 88305 (Level IV - Surgical pathology, gross and microscopic examination, Lymph node, biopsy).

Step 2: Look for Intraoperative Work

Liver cases often involve a pathology consultation during surgery using frozen sections and/or touch preparations. You should be alert to the possibility when you survey the pathology report and look for documentation of the service.

In this case, the pathologist documented a frozen section exam on three margins of the liver wedge resection. You should bill the service as follows:

• 88331— Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen
• Two units of +88332 — … each additional tissue block with frozen section(s) (List separately in addition to code for primary procedure) 

Because the pathologist examines three frozen section tissue blocks from the same specimen, you need to report both codes 88331 and 88332.

Possibility: If the case involved a single frozen section block evaluation on three different specimens, you would code 88331 x 3 instead of 88331 plus +88332 x 2. 

Step 3: Capture Special Stains

The pathology report documents lots of stains on three blocks of the liver wedge resection specimen and the lymph nodes. Let’s sort through how you should bill these services.

First, the H&E stain is a standard stain, so you should not separately bill for the service using a special stain code. Instead, the pathology examination CPT^® code includes the H&E stain service. That means you shouldn’t bill anything for the regional lymph node resection beyond the 88307.

On the other hand, you should separately bill for the trichrome stain and the cytokeratin and other tumor marker stains that the pathologist examines for the three blocks of the liver wedge resection specimen.

Trichrome: Pathologists typically perform a trichrome stain on liver specimens, because the three colors allow them to evaluate the liver for fibrosis from injury or liver disease. You should bill the Gomori’s stain using 88313 (Special stain including interpretation and report; Group II, all other [e.g., iron, trichrome], except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry).  Specifically, you should report 88313 x 3 for the three blocks, because CPT^® includes this note: “Report one unit of 88313 for each special stain, on each surgical pathology block, cytologic specimen, or hematologic smear).”

Payday: Notice that if you missed that little detail about reporting 88313 per block, you might have reported just one unit of 88313 for the trichrome stain, which pays $69.10 (national non-facility global service, conversion factor 35.8043) on the Medicare Physician Fee Schedule (MPFS).  That means you would have sacrificed $138.20 for the trichrome stain on the other two blocks.

Immunohistochemistry (IHC): Pathologists may perform a group of special IHC stains to help identify metastatic adenocarcinoma in the liver. In this case, the pathologist examined four IHC stains: CK7, CK 20, CA-125, and CDX2, on each of the three liver wedge resection blocks. You should report the service using the following codes:

• 88342 — Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure 
• Three units of +88341 — … each additional single antibody stain procedure (List separately in addition to code for primary procedure) 

Alert: Notice that the unit of service is different for 88313 special stains vs. IHC special stains. You should bill the trichrome special stain per block, but you must bill the IHC special stain procedures per specimen. If you report 88342 x 3 (once per block) and +88341 x 9 (three additional IHC stains per block) for this case, you’d be opening your practice to overpayment errors and fraud charges.

Step 4: Get the Diagnosis Right

The ordering diagnosis for this case is liver mass and history of colorectal cancer, but the final diagnosis is hepatic adenocarcinoma, metastatic from colorectal cancer. What should you report?

“You should always code from the final diagnosis on the pathology report if that’s available at the time of billing,” Stainton says.

Do this: Report the diagnosis for the case as C78.7 (Secondary malignant neoplasm of liver and intrahepatic bile duct). You should not report C22.7 (Other specified carcinomas of liver), because C22 has an Excludes 1 note for secondary malignant neoplasm of liver and intrahepatic bile duct (C78.7)

Remember: An Excludes 1 note in ICD-10 means that you must code the condition elsewhere, because it is not included in the listed code. 

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