Pathology/Lab Coding Alert

3 tips can guide LEEP pathology reporting and coding.

If cervical LEEP specimens give you and your pathologists coding fits, you're not alone.

Problem: The tissue that the surgeon submits from a cervical Loop Electrosurgical Excision Procedure (LEEP) is not a "listed" specimen under CPT® surgical pathology exam codes 88302-88309 (Level ..., surgical pathology, gross and microscopic examination ...).

But cervical biopsy (88305, Level III, ... Cervix, biopsy ...) and cervical conization (88307, Level IV ... cervix, conization ...) are listed, and the LEEP procedure could produce either specimen. That means your pathologist must clearly identify and document which cervical specimen the LEEP tissue represents.

Read on to learn expert tips to help you and your pathologist zero in on the proper LEEP specimen code.

Tip 1: Understand Cervical Anatomy

You can think of the uterus as an upside down pear shape, roughly divided into the upper, larger portion called the body, and the lower, narrower portion, called the cervix. The division occurs at the isthmus, which appears as a slight external constriction between the body and the cervix. CPT® refers to the cervix as the "cervix uteri," because it belongs to the uterus, says Melanie Witt, RN, MA, an independent coding consultant in Guadalupita, N.M.

Internally, the uterus contains a cavity, broader in the body and narrowing into the cervical canal. The internal os marks the opening between the uterine cavity and the cervical canal, and corresponds externally to the isthmus.

Focus on the cervix: The cervix has a several areas that you need to understand:

• The ectocervix (or exocervix) is the outside of the cervix just external to where the cervical canal opens into the vagina (called the external os). The ectocervix is made up of squamous cells
• The transformation zone, which is inside the external os, is where the cervical cells change from squamous cells to columnar cells
• The endocervix is above that transformation zone up to the internal os, and is made up of columnar glandular cells.

Tip 2: Use LEEP Surgical Distinctions to Guide Pathology Code

CPT^® distinguishes LEEP procedures based partly on what anatomical part of the cervix is sampled.

A LEEP biopsy samples only as high as the transformation zone, and the surgeon might report the procedure using code 57460 (Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix).

On the other hand, a LEEP conization involves removing a tissue "cone" that takes the ectocervix, transformation zone, and goes up into the endocervix.

The op report might label these specimens "LEEP conization" and indicate a procedure code such as one of the following:

• 57522 (Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision)
• 57461 (Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix).

"If the surgical report indicates a LEEP biopsy procedure or a LEEP conization procedure, and the tissue is consistent with the designation, you can use the surgical code to document and define the pathology specimen," says R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services in Jonesboro, Ark.

That means reporting 88305 for a LEEP biopsy, and 88307 for a LEEP conization specimen.

Tip 3: Clarify Multiple LEEP Specimens

Sometimes the surgeon submits multiple LEEP specimens, possibly as two or three parts of a LEEP conization procedure or as distinct LEEP biopsies. In those cases, you should never bundle individually-submitted specimens into a single charge code.

Instead, the pathologist must determine for each separately-submitted specimen whether the exam is equivalent to the work of a cervical biopsy or a cervical conization.

Documentation: Ideally, the pathology report should use CPT^® terminology - biopsy or conization - to audit-proof the coder's choice of code assignment. Also, you should expect to see evidence in the pathology report of certain work, such as multiple blocks and margin exam, to justify an 88307 code.