Pathology/Lab Coding Alert

Whatever the otolaryngologist excises, the pathologist examines. But coding these sometimes-complex surgical pathology specimens can be a pain in the neck. You need to learn your way around bundling rules and bilateral procedures to ensure that you capture all the payment due for services your pathologist provides. Use the following three tips provided by pathology coding experts .

1. Translate Surgical Procedures to Pathology Specimens

Surgical pathology codes 88300-88309 list many head and neck specimens that pathologists routinely examine. But the surgical terms you see in the operative report may not look at all like the pathology specimen list. You must learn to translate what the surgeon delivers into proper coding for surgical pathology specimens.

Although the surgeon may submit tissue from a single procedure such as a thyroidectomy with limited neck dissection (60252, Thyroidectomy, total or subtotal for malignancy; with limited neck dissection), the pathologist must examine each surgical pathology specimen separately. "In this case, the pathologist would perform two services an examination of the thyroid and a separate examination of the lymph node resection," says Stephen Yurco III, MD, partner and pathologist at Clinical Pathology Associates in Austin, Texas. Report the thyroid surgical pathology exam as 88307 (Level V Surgical pathology, gross and microscopic examination, thyroid, total/lobe) and the cervical lymph node examination as an additional 88307 ( lymph nodes, regional resection).

Table 1 shows common head and neck surgical procedures and the CPT codes for surgical pathology specimens they yield. "Even if the surgeon submits the tissue en masse, you should code separately for each surgical pathology specimen that the pathologist identifies and diagnoses in the pathology report," says Debbie Siena, HT, QIHC (ASCP), manager of Tissue Techniques Pathology Laboratory in Dallas. In some cases, however, the surgeon must distinguish separate specimens for the pathologist to consider them individually  such as identifying left and right tonsils, or left and right cervical lymph nodes.

2. Look Out for Bilateral Cervical Lymph Nodes

Because the neck contains both left and right cervical lymph nodes, you should be alert to the distinction between unilateral or bilateral neck dissections. "If the surgeon identifies both left and right lymph nodes, either as neck dissections or as adjuncts to a primary specimen such as tongue, you should report them separately [88307 x 2] unless they are bundled with the primary specimen," Siena says.

3. Know Lymph Node Bundling Rules

Because of lymph node bundling rules, coding for pathologists' examination of laryngectomy is different from other neck specimens, as shown in Table 1. CPT bundles lymph nodes with certain surgical pathology specimens, and the larynx is one of them. Report a laryngectomy without associated lymph nodes as 88307 ( larynx, partial/total resection) and with associated lymph nodes as 88309 ( larynx, partial/total resection with regional lymph nodes). "You should report 88309 for a laryngectomy with either unilateral or bilateral neck dissection because CPT doesn't allow unbundling regional lymph nodes from the larynx," Yurco says.

Surgeons occasionally submit a left or right cervical lymph node chain in separate sections to evaluate metastatic disease progression. For example, the surgeon may separately identify and place in separate containers multiple nodes from different zones of a neck dissection identified as upper, middle and lower regions. "The question is whether to code this scenario as one specimen or three," Yurco says. CPT guidelines in the preamble to the surgical pathology section state, "A specimen is defined as tissue or tissues that is [are] submitted for individual and separate attention, requiring individual examination and pathologic diagnosis." "This indicates that if the pathologist examines and provides a diagnosis for multiple lymph nodes in each of the three regions identified by the surgeon, you should report three units of 88307," Siena says.