Pathology/Lab Coding Alert

Add Up Specimens to Report Radical Cystectomy

Published on Tue Apr 01, 2003

Pathologists aren't the only ones who have to separate tissues submitted from major surgical procedures coders do too. When the surgeon sends a radical cystectomy en bloc, you should code the case based on the individual specimens examined by the pathologist.

"Regardless of how the surgeon submits the tissue, you should report the pathologist's work based on the CPT Codes specimen definitions and adjunct services provided, such as frozen sections or special stains," says R.M. Stainton Jr., MD, president of Doctor's Anatomic Pathology, an independent pathology laboratory in Jonesboro, Ark. CPT defines a surgical pathology specimen as "tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis," and lists about 180 individual specimens under surgical pathology codes 88302-88309.

Case Study Exemplifies Coding Strategy

Not all radical cystectomies are created equal surgeons remove different tissues based on the particular patient and condition. Use the following case as an example of how to code these complex surgical procedures:

The radical cystectomy consisted of a bladder and attached left and right distal ureter segments with adhering prostate. The surgeon also submitted in separate jars four left obturator lymph nodes and three right obturator lymph nodes.

The pathologist reports the following:

Bladder examination poorly differentiated transitional cell carcinoma

Prostate examination glandular hyperplasia and necrotizing granulomatous inflammation, negative for acid fast and fungal stains

Left distal ureter margin examination one frozen section and ureter examination negative for tumor

Right distal ureter margin examination two frozen sections from one block and ureter examination negative for tumor

Left obturator regional lymph node resection two frozen sections from each of two blocks and examination of nodes negative for tumor

Right obturator regional lymph node resection frozen section and examination of nodes negative for tumor.

Assign Codes by Specimen,Service

"Although surgeons often remove the prostate in a radical cystectomy, it is a separate, listed specimen requiring individual examination and diagnosis, so you should code it as such," Stainton says. Code services for the bladder and prostate as follows:

Bladder 88309 (Level VI Surgical pathology, gross and microscopic examination, urinary bladder, partial/total resection)

Prostate 88307 (Level V Surgical pathology, gross and microscopic examination, prostate, except radical resection)

"This prostate specimen is similar to an open prosta-tectomy rather than a radical prostatectomy for tumor, so the appropriate code is 88307 rather than 88309," Stainton says.

Acid fast bacillus stain and fungal stain for prostate histopathology Report two units of +88312 (Special stains [list separately in addition to code for surgical pathology examination]; Group I for microorganisms [e.g., Gridley, acid fast, methenamine silver], each)

"You should report 88312 x 2 because the code definition states 'each,'meaning that you report 88312 once per stain per specimen," says Beverly Bloedow, coding resource specialist for Hospital Pathology Associates in Minneapolis, which provides pathology services to Allina Hospitals throughout Minnesota and Wisconsin. Common tissue fungal stains include Gomori methenamine silver and Gridley's fungus.

"The pathologist provides frozen section evaluation intraoperatively, followed by later tissue examination of the left and right ureters to ensure clear surgical margins," Stainton says. Consequently, you should code the ureter services as follows:

Left distal ureter, one frozen section 88331 (Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen)

Left distal ureter tissue examination 88305 (Level IV Surgical pathology, gross and microscopic examination, ureter, biopsy)

"The pathologist only examines the distal portion of the ureter, which is comparable to a biopsy rather than a ureter resection (88307)," Stainton says.

Right distal ureter, two frozen sections from one block 88331. Notice that the number of frozen sections does not change this code assignment as long as the sections are from the same block and from the same specimen.

Right distal ureter tissue examination 88305.

You should assign separate codes for the lymph node services because CPT does not bundle lymph nodes with urinary bladder or prostate specimens. "Report the left right regional obturator lymph nodes as two separate resections," Bloedow says.

Code the lymph node frozen sections and tissue examinations as follows:

Left obturator lymph node frozen sections 88331 for the two frozen sections from the first tissue block and 88332 ( each additional tissue block with frozen section[s]) for the two frozen sections from the second tissue block. "Because the multiple lymph nodes are part of a single, regional lymph node resection specimen, you would code this as two frozen section blocks from a single specimen 88331 and 88332 rather than two frozen section blocks from two specimens 88331 x 2," Bloedow says.

Left obturator regional lymph node resection examination 88307 (... lymph nodes, regional resection)

Right obturator lymph node frozen sections 88331 for the single frozen section from this specimen

Right obturator regional lymph node resection examination 88307.