Pathology/Lab Coding Alert

Between Correct Coding Initiative (CCI) edits and conflicting guidance about reporting 88321-88325 with special stains, who knows what to do? Let our experts sort out the confusion with three rules of engagement.

Know the codes: The following codes describe pathology consultations on slides and/or other material (such as a tissue block) referred from an outside laboratory:

• 88321 -- Consultation and report on referred slides prepared elsewhere

• 88323 -- Consultation and report on referred material requiring preparation of slides

• 88325 -- Consultation, comprehensive, with review of records and specimens, with report on referred material.

Consider the following three tips to learn when and how you can report special stains in addition to these consultation codes.

Then, make sure you've mastered the ground rules for using 88321-88325 by reading "Conquer Consultation Confusion -- Here's How," on page 101.

When your pathologist consults on a cytology or histology case from an outside institution, the case might include slides that involve special stain and immunhistochemistry preparations described by the following codes:

• 88312 -- Special stains; Group I for microorganisms (e.g., Gridley, acid fast, methenamine silver), including interpretation and report, each

• 88313 -- ... Group II, all other (e.g., iron, trichrome), except immunocytochemistry and immunoperoxidase stains, including interpretation and report, each

• +88314 -- ... (List separately in addition to code for primary service) histochemical staining with frozen sections

• 88342 -- Immunhistochemistry (including tissue immunoperoxidase), each antibody.

Caution: If the referring lab prepared the special stain slides, you should not report the special stain code in addition to the consultation. The consultation codes include all slides that a pathologist previously diagnosed and sent for a consultation, regardless of the type of slide.

Watch for edits: To affirm this billing restriction, Medicare's Correct Coding Initiative (CCI) bundles each of the outside consult codes with each of the special stain codes.

What if you receive slides for a consult, but your lab also prepares special stains from a tissue block that came with the slides? Correct coding depends on the specifics of the case -- and on whom you ask.

If the lab prepares hematoxylin and eosin (H&E) as well as special stain slides for the pathology consultation on referred material, you should report 88323 plus the appropriate additional procedure code, such as 88312.

Global billing includes both the technical and professional services.

"Everyone agrees that you should bill 88323 plus the special stain code if the lab makes additional routine preparations along with the special stain or immunohistochemistry slides," confirms Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., publisher of the Pathology Service Coding Handbook, in The Villages, Fla.

If the lab prepares only special stain slides with a consult case (that is, no additional H&E preparations as well), the coding is more controversial. "Authoritative sources provide conflicting information about when to report 88321 or 88323 with special stains for consultation cases," says Elizabeth Sheppard, HT(ASCP), senior manager, technical marketing for Ventana Medical Systems in Tucson, Ariz.

You should check with your regional CMS office to assure that you're coding to meet their reimbursement requirements, she says.

CMS says: When the lab prepares only special stain slides with a consult case, you should code 88323 plus the appropriate special stain code. According to the CCI policy manual, you should report 88312, 88313, or 88342 with 88323 if the consulting pathologist "performs and interprets these stains de novo."

"I believe this CMS rule makes sense. The lab performs significant additional work prepping the block to produce special stain slides beyond what they do in 88321 cases that involve only extant slides," Padget says.

"Furthermore, the pathologist's work is expanded as well, so simply reporting the additional procedure code like 88313 or 88342 doesn't really capture the extra professional and technical resources."

That's why reporting the basic consultation service at the 88323 level when the lab prepares only special stain slides with a consult case "certainly seems more realistic," according to Padget. "That said, the CAP [College of American Pathologists] and the AMA [American Medical Association] give different instructions than CMS," he concedes.

CAP says: What if you receive a consult case that includes slides as well as a tissue block, which you use for IHC stains, but not additional H&E stains? You should report this case as 88321 plus 88342, according to the Oct.

2001 CAP Today. "I've corresponded with the AMA on this matter, and it appears to support the College's position instead of CMS's," adds Padget.

Tip: Confer with your compliance officer to establish a consistent coding policy for special-stain-only consult  cases. "The more I think about it, the more I conclude that CMS has the right take on proper coding for this type of consult case," Padget advises. "Plus, there's little risk from other insurers when you've got the weight of the federal government on your side."

Don't forget modifier: Whether you report 88321, 88323, or 88325 with de novo special stain procedures, you'll have to append modifier 59 (Distinct procedural service) to the special stain code to override the CCI edit.