Pathology/Lab Coding Alert

Don’t miss bundling restrictions.

When your pathologist evaluates a surgical Whipple resection case, you have lots of chances to capture payment opportunities — or make coding blunders that could cost you.

Let our experts break Whipple-exam coding down for you into four easy steps so you can sail through these claims with ease.

Step 1: Understand Whipple Procedure

Whipple resection is a surgical treatment for pancreatic cancer. Problem is, the pancreas is closely associated with other organs, so removing part of the pancreas necessarily involves removing all or part of other organs, such as part of the small intestine and stomach, the gallbladder, and the common bile duct. That means your pathologist might receive an en-bloc resection or separate “parts.” The pathologist and you, the coder, must determine what constitutes separate specimens for pathological examination, diagnosis, and coding.

Tip: The op report your pathologist receives may or may not specifically state “Whipple procedure.” You might see a report by many other names, such as pancreaticoduodenectomy, pancreatoduodenectomy, pancreatectomy with duodenectomy, Kausch or Kausch-Whipple procedure, or pylorus-sparing pancreaticoduodenectomy (Traverso-Longmire procedure).

Even if the word “Whipple” is nowhere in sight in the pathology report, you’ll still follow the same principles for coding the case. And the principle is: identify each tissue specimen and determine if that tissue is bundled or separately reportable as a surgical pathology exam.

Step 2: Identify Pathology Specimens

Regardless of the name, all Whipple procedures involve removing the head of the pancreas and at least a portion of the duodenum, according to Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

Maybe more: “In addition to the pancreas and duodenum, tissue received from a Whipple resection might include the gallbladder, the spleen, a portion of the stomach, the common bile duct, lymph nodes and other tissues,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark.

Coding rules: The introduction to the surgical pathology CPT^® section states that the “specimen” is the unit of service for surgical pathology codes, and defines the specimen as “tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis.” Coders are also told that “Two or more such specimens from the same patient are each appropriately assigned an individual code reflective of its proper level of service.” That means you should separately code individual separate specimens that the pathologist receives in a Whipple case, subject to bundling rules, which you’ll read about in Step 3.

The following list of tissues and codes describe surgical pathology specimens that the pathologist might examine for a Whipple case:

• Pancreas resection (88309 Level VI - surgical pathology, gross and microscopic examination … pancreas, total/subtotal resection …)
• Duodenum (88307, Level V - surgical pathology, gross and microscopic examination … small intestine, resection, other than for tumor …)
• Stomach (88307, ... stomach - subtotal/total resection, other than for tumor…)
• Lymph node resection (88307, … lymph nodes, regional resection…)
• Cholecystectomy (88304, Level III - surgical pathology, gross and microscopic examination … gallbladder…)
• Spleen (88305, Level IV - surgical pathology, gross and microscopic examination … spleen…)
• Bile duct biopsy (88305). CPT^® does not list bile duct as a surgical pathology specimen. However, instructions for the surgical pathology section states that “Any unlisted specimen should be assigned to the code which most closely reflects the physician work involved when compared to other specimens assigned to that code.” The bile duct biopsy typically requires the level of work comparable to other listed biopsy specimens, and so warrants an 88305.

Depending on the tissues documented by your pathologist, you might be able to individually report many of the above codes for a Whipple case — but not until you subject the case to a review of principles outlined in Step 3 below.

Step 3: Avoid Bundling Pitfalls

Just seeing a type of tissue named in the pathology report doesn’t automatically mean that the tissue meets the CPT^® definition of a specimen “submitted for individual and separate attention.”

Example: Pancreas resections typically include attached peripancreatic lymph nodes that the surgeon removes incidentally. That means you shouldn’t code a separate unit of 88307 for a lymph node resection for attached peripancreatic lymph nodes. Those nodes are an incidental part of a pancreas resection, and are bundled into the 88309 pancreas resection code.

Caveat: “On the other hand, if the surgeon submits a distant regional resection such as the periportal lymph nodes, and the pathologist separately evaluates those nodes, you should report 88307 in addition to the 88309 for the pancreas resection,” Stainton says.

Step 4: Don’t Miss Additional Pathology Services

During the Whipple procedure, the surgeon often requests a pathology consultation to evaluate the pancreas resection margin for tumor. Based on the pathologist’s findings, the surgeon will either know that the tumor margins are clear, or will excise more tissue in an effort to obtain a clear margin.

Pathologists typically examine frozen sections to evaluate resection margins intraoperatively, and report the findings to the surgeon while the patient is still in surgery. To bill for this service, you should turn to the following codes:

• 88331 (Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen)
• +88332 (… each additional tissue block with frozen section(s) (List separately in addition to code for primary procedure)).

Unit of service: Frozen section(s) from a single tissue block represent one unit of service for an intraoperative “frozen section” consultation. If the pathologist examines frozen sections from multiple tissue blocks that the pathologist processes from a single specimen, you should report 88331 for the frozen section(s) examined from the first tissue block, and +88332 for frozen section(s) from each additional tissue block examined from the same specimen.

Example 1: The pathologist processes the distal pancreas resection margin, Specimen A, in two blocks, and examines frozen sections from each block. The pathologist finds abnormal cells in one of the blocks and reports to the surgeon that the margin is not clear. You should report the service as 88331 and +88332.

Example 2: After receiving the pathologist’s intraoperative report, the surgeon submits two additional separately-identified margin specimens for frozen section exam. The pathologist processes each specimen as a single block, labeled Specimens B and C, and examines frozen sections from each specimen block. The pathologist reports the findings from each specimen to the surgeon while the patient is still on the table. You should report this service as two units of 88331, because the pathologist examined a first tissue block from two separate specimens, in this case.