Pathology/Lab Coding Alert

Let diagnoses lead your procedure code choice.

The surgeon may have described a hemorrhoidectomy, but if you take that on face value instead of carefully reading the pathology report, you have a lot to lose.

Look at the following case to brush up on how an understanding of diagnosis coding and separate specimens can impact your pathologist’s pay.

Case: Female patient, age 62

Specimen Source: Closed internal hemorrhoidectomy

Clinical History: Rectal bleeding, flexible sigmoidoscopy, stage III hemorrhoids

Gross Description: Specimens received and labeled as follows:

A: Thrombosed internal hemorrhoid, lithotomy 8-9 o’clock position. The specimen is serially sectioned, with two sections submitted in cassettes A1 to A2

B: Internal hemorrhoid column, lithotomy 1 o’clock position. The specimen is serially sectioned, with three sections submitted in cassettes B1 to B3.

C: Suture and surgeon’s note identifying hemocystic swelling with superficial ulceration in hemorrhoid column, lithotomy 1 o’clock position. The sutured spot is serially sectioned and submitted in cassette C.

Microscopic Description: Final diagnosis based on a microscopic exam of representative sections for specimens A, B, and C.

Make Sure the ‘S’ Doesn’t Fool You

The surgeon submits separately identified hemorrhoids in this case: an internal hemorrhoid from the lithotomy 8-9 o’clock position, and a column of internal hemorrhoids from the lithotomy 1 o’clock position.

The procedure code for the pathologist’s evaluation of hemorrhoids is 88304 (Level III - Surgical pathology, gross and microscopic examination, Hemorrhoids). But don’t let a common myth force hemorrhoid specimens into an artificial charge bundling rule. Although 88304’s descriptor “hemorrhoids” is plural, you can bill multiple units for separately identified hemorrhoid specimens.

“An ‘s’ added to the specimen name in the CPT^® text does not indicate an exception to the general pathology coding principle that you should separately code each individually identified specimen,” says R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services in Jonesboro, Ark. “For hemorrhoids, as with other plural listed specimens — fingers, toes, nasal polyps — you should report one unit of the appropriate code for each specimen that the surgeon individually submits and the pathologist separately diagnoses.”

In this case, the surgeon submits two distinct internal hemorrhoid specimens identified by location: one from lithotomy position 8-9 o’clock, and a column of hemorrhoids from lithotomy position 1 o’clock. The pathology report indicates that the pathologist separately diagnoses these two specimens (A and B), so you can legitimately charge 88304 x 2 for the hemorrhoidectomy pathology exam.

Notice: Although specimen B is a column containing multiple hemorrhoids, you can bill just one unit of 88304 for that specimen. The surgeon nor the pathologist distinguishes the individual hemorrhoids that are part of the excised column from lithotomy position 1 o’clock.

Identify Distinct Mark, Diagnosis

Because the surgeon placed a suture in the excised hemorrhoid column and distinctly noted the hemocystic swelling with superficial ulceration, the pathologist separately processes and examines that tissue as specimen C. The pathologist notes cellular changes and identifies the lump as a hyperplastic polyp of the rectum.

Do this: You should separately bill for the pathologist’s exam and diagnosis of the sutured spot as a hyperplastic polyp using 88305 (Level IV - Surgical pathology, gross and microscopic examination, Polyp, colorectal).

Reward: Capturing the additional specimen identified and diagnosed in the excised tissue means that you’ve earned $74.11 for your pathologist that would have otherwise been lost (based on Medicare Physician Fee Schedule facility National Limit Amount, conversion factor 35.8043).

Round Up the Case Coding

Let’s look at the final info you should report for this case:

CPT^®: You should list 88304 x 2 and 88305 for this hemorrhoidectomy case.

ICD-10: Report the hemorrhoid diagnosis as K64.2 (Third degree hemorrhoids). For the hyperplastic polyp, list K62.1 (Rectal polyp).

Coder tip: Because the surgeon identifies the specimen as an internal hemorrhoid, you know that the excised tissue is proximal to the dentate line, meaning that the appropriate code is K62.1, not one of the other benign polyp codes such as K63.5 (Polyp of colon) or K62.0 (Anal polyp).