Pathology/Lab Coding Alert

CPT 88309 is just the beginning

For a pathologist's radical prostatectomy examination, you might report a single code (88309, Level VI - surgical pathology, gross and microscopic examination, prostate, radical resection), or you might report several other codes in addition to 88309. How you report the service depends on several factors -- like bundling rules, how the surgeon submits the resected tissue, and what the pathologist does with it.

1. Choose the Correct Surgical Pathology Level

First you have to find "prostate" out of the approximately 180 listed specimens under CPT surgical pathology codes 88302-88309. Once you see that CPT includes prostate four times, as shown in the following list, you'll have to pick the right code based on the type of prostate tissue.

88305 -- Level IV - surgical pathology, gross and microscopic examination, prostate, needle biopsy

88305 -- Level IV - surgical pathology, gross and microscopic examination, prostate, TUR

88307 -- Level V - surgical pathology, gross and microscopic examination, prostate, except radical resection

88309 -- Level VI - surgical pathology, gross and microscopic examination, prostate, radical resection.

"An 88309 radical prostate resection involves the entire prostate gland and almost always includes the attached seminal vesicles," says Stephen Yurco III, MD, partner and pathologist at Clinical Pathology Associates in Austin, Texas. The resection may also include a segment of vas deferens, fatty tissue, and the prostate/bladder neck junction.

You should report 88307 for a sub-total prostate resection that involves less tissue than a radical resection. Use 88305 for two different types of prostate tissue -- needle biopsy specimens, or portions of resected prostate tissue removed through a transurethral approach.

Requirement: Report the surgical pathology code (88305-88309) that best describes the type of prostate specimen.

2. Don't Unbundle En Bloc Prostatectomy Submission

Submitted en bloc, a radical prostatectomy that includes attached seminal vesicles, surrounding fatty tissue, and prostate/bladder neck junction fits the CPT definition of a surgical pathology specimen -- tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis. Code 88309 describes this specimen.

"As a radical resection, you'd expect to receive small amounts of other tissue attached to the prostate, and you shouldn't code them separately," Yurco says.

Although not specified by CPT, the College of American Pathologists (CAP) has advised that you should always bundle seminal vesicles with a radical prostate resection. "Seminal vesicles are part of a radical resection of the prostate and would not be separately coded, even if submitted in a separate container," states CAP Today, July 1999.

Hidden trap: Don't ignore bundling conventions.

3. Sometimes You Should Report Separate Specimens

Sometimes you should code individually for other tissues that the surgeon submits with a radical prostatectomy. "Lymph nodes are a good example, because prostate resections do not typically involve attached lymph nodes,"  Yurco says. CPT does not bundle lymph nodes with prostate as it does for some specimens, such as breast.

For each individually identified group of lymph nodes, report one unit of 88307 (Level V - surgical pathology, gross and microscopic examination, lymph nodes, regional resection). "You might have multiple units of 88307 if the pathologist examines more than one regional lymph node resection, such as the left and right pelvic nodes," Yurco says. If the surgeon submits an individual node rather than a regional resection, use 88305 (Level IV - surgical pathology, gross and microscopic examination, lymph node, biopsy).

Although you don't separately report the resected prostate/bladder neck junction that the surgeon submits as part of a radical prostatectomy, some circumstances might warrant a separate code. "If the surgeon separately identifies and submits surgical margins, such as a portion of the bladder or urethra, you should report an additional code for the pathologist's separate specimen examination," says R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark. In addition to 88309 for the prostate resection, report 88305 (Level IV - surgical pathology, gross and microscopic examination, urinary bladder, biopsy) for the individual bladder exam, for example.

Opportunity: Bill for lymph nodes in addition to the radical prostatectomy.

4. Remember to Code Adjunct Procedures

"During the prostatectomy procedure, the surgeon may request a consultation from the pathologist involving frozen sections or touch preps to evaluate margins and help guide the resection," Yurco says. Depending on the consultation and slides examined, you would report some combination of the following codes:

88329 -- Pathology consultation during surgery

88331 -- ... first tissue block, with frozen section(s), single specimen

88332 -- ... each additional tissue block with frozen section(s)

88161 -- Cytopathology, smears, any other source; preparation, screening and interpretation.
 
Be aware that a National Correct Coding Initiative edit prohibits reporting touch preps (88161) together with intraoperative consults involving frozen sections (88331, 88332).

The pathologist may perform special stains as part of the prostate examination, such as an acid fast bacillus for observed granulomas (+88312, Special stains [list separately in addition to code for primary service]; Group I for microorganisms [e.g., Gridley, acid fast, methenamine silver], each). You should report each special stain using the appropriate code, in addition to 88309 for the prostate exam. 

Don't overlook: Make sure you capture adjunct procedures, but avoid NCCI edit-pair code combinations.