Pathology/Lab Coding Alert

Don’t miss frozen section charge, either.

When your pathologist receives kidney tissue from a “staged” nephrectomy procedure, you might be leaving money on the table if you try to “add up” specimens in the report.

Let our experts walk you through the following case study to make sure you have the tools you need to secure the pay you deserve for your pathologist’s work.

Case: A 58-year-old man presents for surgery with an identified 3 cm right renal mass suspicious for renal cell carcinoma. The surgeon performs a laparoscopic partial nephrectomy, calls the pathologist for an intraoperative consultation, and submits the specimen for pathology examination and diagnosis.

The pathologist processes a portion of the specimen intraoperatively as three blocks oriented perpendicular to the inked surgical margin, examining serial frozen sections from each block. The pathologist identifies cells with clear or eosinophilic cytoplasm within a vascular network, and notes that the renal parenchymal margin is not clear.

Based on the margin findings, the surgeon proceeds with a total nephrectomy and submits the specimen to the pathologist for evaluation.

The pathologist processes the partial nephrectomy specimen “A” in cassettes A1-A4, and the total nephrectomy specimen “B” in cassettes B1-B6. The pathologist runs an immunohistochemistry (IHC) panel of PAX-8, CA IX, CK7, and AMACR on sections from cassettes A2 and A3 that demonstrate clear cells with preserved cell membranes in solid areas tumor. The panel findings of PAX-8 and CZ IX, positive but and CK7 and AMACR negative help differentiate the tumor as Clear Cell RCC (CCRCC).

Bill for Frozen Section Consult

Because the pathologist performs an intraoperative consult on frozen sections for the initial partial nephrectomy, you should submit a separate charge for that part of the pathologist’s work.

“The work involves three frozen section blocks from a single specimen,” points out R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services in Jonesboro, Ark.

That means you should bill 88331 (Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen) for the initial block, and two units of +88332 (…each additional tissue block with frozen section[s] [List separately in addition to code for primary procedure]) for the additional two blocks.

See How ‘Staged’ Surgery Impacts Pathology Exam

In this case, the surgeon performed the intended procedure to treat the patient — partial nephrectomy. Based on the intraoperative consultation findings, however, the surgeon proceeded to perform a second procedure on the same date.

Because the surgeon performs two procedures, your pathologist receives and examines two distinct specimens, which you should bill as follows:

• Specimen A - partial right nephrectomy: 88307 (Level V - Surgical pathology, gross and microscopic examination … Kidney, partial/total nephrectomy …)
• Specimen B - total nephrectomy of remaining right kidney: 88307.

“When you receive two distinct nephrectomy specimens separately submitted by the surgeon, you should not ‘bundle’ the tissue into a single specimen,” Stainton says. “In this case, the pathologist examines two distinct kidney resections that are separately billable.”

Big deal: If you artificially bundled the two specimens into a single 88307 charge, you would stand to lose $312.21 of legitimate pay (2016 Physician Fee Schedule national facility amount, conversion factor 35.8043).

Don’t confuse total with radical: If the pathologist receives a “radical” nephrectomy as opposed to a “total” nephrectomy specimen, you should be on the lookout for additional, separately-chargeable tissue, such as the adrenal gland, lymph nodes, ureter, or renal vein. The case at hand doesn’t document any of these additional tissues.

Jump On IHC Charges

The pathologist examines specimen A in this case using four different IHC stains: PAX-8, CA IX, CK7, and AMACR.

Do this: Bill the service as 88342 (Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure) and three units of +88341 (…each additional single antibody stain procedure [List separately in addition to code for primary procedure]).

Avoid: Although the report indicates that the pathologist examined these four IHC stains on slides from cassettes A1 and A2, you should not bill the stains separately for the different cassettes. The unit of service for these stains is each “single antibody stain,” “per specimen,” regardless of the number of blocks or slides that receive the stain.