Pathology/Lab Coding Alert

Bundles aren't always 'hard and fast.'

With six "ovary" listings and five bundling references in CPT® surgical pathology codes, not to mention a host of ICD9 options, you have a lot of choices to make when coding your pathologist's ovary exam.

Hone your oophorectomy coding skills with the following three case studies to make sure you select the proper code(s) and capture all the reimbursement your pathologist earns.

Case 1: Beware Adnexal Bundling Rules

A 48-year-old patient complains of right iliac abdominal pain, and the physician palpates a right adnexal mass. Following pelvic ultrasound indicating an enlarged ovarian mass, a surgeon performs a right salpingo-oophorectomy and sends the tissue to the pathologist for diagnosis.

The pathologist finds endometrial implantation in the ovary and diagnoses an endometrial cyst. Also called a "chocolate cyst," the ovary shows evidence of hemorrhage and formation of hematoma containing old, brown blood. The pathologist notes that the fallopian tube is unremarkable.

Solution: You should report the pathologist's work as 88305 (... Ovary with or without tube, non-neoplastic) because an endometrial cyst is non-neoplastic.

"Although the pathology report includes a diagnosis statement for the fallopian tube, and CPT® provides a code for fallopian tube (88305, ... Fallopian tube, biopsy), you should not separately code the tube exam," cautions R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.

The 88305 ovary code states, "with or without tube," so you should not unbundle the tube charge.

Assign diagnosis code 617.1 (Endometriosis of ovary) for the case. Don't confuse endometrial cyst with endometrioid tumor, which is a type of malignant epithelial carcinoma (183.0, Malignant neoplasm of ovary).

Case 2: Look for Lymph Nodes

Based on pelvic exam and ultrasound findings and elevated CA-125 test results, the pathologist receives a unilateral oophorectomy specimen and pelvic and para-aortic lymph node biopsies from a 54 year old patient.

The pathologist examines the ovary and diagnoses invasive ovarian cancer originating in the epithelium. The pathologist also evaluates the pelvic lymph node biopsy and reports findings positive for metastatic epithelial carcinoma. The report lists similar findings for the para-aortic lymph node biopsy, and the final diagnosis is stage III ovarian epithelial cancer.

Solution: You should code the ovary exam as 88307 (... Ovary with or without tube, neoplastic), because ovarian epithelial carcinoma is a malignant neoplasm. Because CPT® does not bundle lymph nodes with ovaries as it does with some specimens, you can separately code each documented lymph node biopsy as 88305 (... Lymph node, biopsy). The pathologist separately examines and diagnoses a lymph node biopsy from the para-aortic and pelvic regions, so you should report 88305x2.

Code diagnosis, too: "In this case you should report 183.0 (Malignant neoplasm of ovary) to describe the stage III epithelial ovarian cancer, says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M.

You can tell from "stage III" that the neoplasm is malignant, Witt notes. Under the system used for staging, stage III ovarian cancer means the cancer is in one or both ovaries and has spread to the abdominal lining, the lymph nodes, or both.

Don't miss: A note with 183.0 says to "use additional code to identify any functional activity."

In this case, the physician reported an elevated CA-125 prior to surgery, "so you can add the appropriate code (795.82, Elevated cancer antigen 125 [CA 125]) as a secondary diagnosis," Witt says.

Case 3: Catch Separate Ovary Opportunity

A 32-year-old woman presents with symptoms of abdominal pain and severe irregular vaginal bleeding unrelated to her menstrual cycle (626.6, Metrorrhagia). The physician performs a pelvic examination and finds an enlarged uterus. Ultrasound indicates presence of large fibroid tumors, and the patient is scheduled for a hysterectomy.

The pathologist receives the surgical specimen consisting of uterus and bilateral tubes and ovaries. Surgical pathology examination identifies submucous leiomyoma with pedunculated nodules, which may be associated with intermenstrual bleeding.

The pathologist notes unremarkable right adnexa, but identifies a left cystic ovary. The pathology report describes a monolocular ovarian cyst with a membranous lining containing firm thickened areas, soft yellow matter, hair, and calcified areas, which the pathologist diagnoses as a dermoid cyst (cystic teratoma).

Solution: You should report the pathologist's examination of the fibroid uterus as 88307 (... uterus, with or without tubes and ovaries, other than neoplastic/prolapse). Although leiomyoma is a neoplasm, you shouldn't list 88309 (... uterus, with or without tubes and ovaries, neoplastic) because leiomyoma represents an exception based on coding convention enjoined by the AMA (CPT Assistant® Dec. 2003) and the College of American Pathologists (CAP Today July 1999).

Although the surgeon removes tubes and ovaries as an adjunct to the uterus, the pathologist identifies and diagnoses unique pathology in the left ovary, which warrants an additional charge of 88307 (...Ovary with or without tube, neoplastic), because a dermoid cyst is a benign neoplasm.

Caution: Just as CPT® bundles fallopian tubes with ovaries, the uterine codes bundle adnexa with uterus. But because the left ovary in this case represents a distinct, significant pathology from the uterus and requires individual examination and diagnosis, it fits the CPT® definition for a separate specimen and warrants a separate charge.

Diagnosis: Your report for this case should show two diagnosis codes, one for the uterine fibroids and one for the dermoid cyst, as follows:

• 218. 0 -- Submucous leiomyoma of uterus
• 220 -- Benign neoplasm of ovary

Cystic teratoma is a benign ovarian neoplasm that develops when an immature egg is retained in the ovary and begins to differentiate without fertilization, resulting in a variety of tissue including hair, teeth, bone and sebaceous material.