Pathology/Lab Coding Alert

Anatomic Pathology:

Jump Start Upper GI Exam Pay With These 3 Tips

Published on Mon Aug 09, 2021

Don’t miss multiple specimens.

Pathologists often examine multiple specimens from a single upper gastrointestinal (GI) surgical procedure, but missing the nuance of how to select the anatomic pathology code(s) could cost your practice.

Let our experts guide you through the pitfalls and opportunities to make sure you get the coding right when you face these cases.

Tip 1: Know Your Code Choices

When the surgeon submits pathology specimens from an upper GI procedure such as esophagoscopy, esophagogastroduodenoscopy (EGD), push endoscopy, or open procedure such as enterectomy, the surgical procedure should narrow your focus to specific CPT^®codes.

The following codes represent pathology examination of specimens from an endoscopy (enteroscopy) or open upper GI procedure you might encounter:

88304 (Level III - Surgical pathology, gross and microscopic examination … diverticulum - esophagus/small intestine)
88305 (Level IV - Surgical pathology, gross and microscopic examination … duodenum, biopsy … esophagus, biopsy … polyp, stomach/small intestine … small intestine, biopsy … stomach, biopsy …)
88307 (Level V - Surgical pathology, gross and microscopic examination … small intestine, resection, other than for tumor … Stomach - subtotal/total resection, other than for tumor)
88309 (Level VI - Surgical pathology, gross and microscopic examination … Esophagus, partial/total resection … small intestine, resection for tumor … Stomach - subtotal/total resection for tumor)

88305-88304: Code 88304 describes a specimen from the stomach or small intestine that contains small, herniated sac(s) of the interior wall, called diverticula. On the other hand, 88305 encompasses all endoscopy specimens that are tissue biopsies or polyps. A biopsy involves a sampling of tissue for examination and diagnosis without an effort to remove the entire lesion, while a polyp is a stalk-like growth arising from the mucous membrane.

Resection: In contrast to a biopsy, a tissue resection involves excising a section of the organ to remove the entire lesion, typically for treatment and diagnosis. You might encounter the term “enterectomy” to refer to small intestine resection Notice that CPT^®divides pathology resection exams into two codes — 88307 and 88309. Report 88307 when the resection is for a reason other than tumor, such as a section of strangulated small intestine. Report 88309 when the surgeon performs the resection for suspected tumor, requiring the pathologist to examine the tissue for clear margins.

“The distinction between a small intestine resection exam that you report as 88307 or 88309 is whether the pathologist evaluates the specimen for tumor — even if the final diagnosis is not a neoplasm,” says Peggy Slagle, CPC, coding and compliance manager for Regional Pathology Services at the University of Nebraska Medical Center in Omaha.

Tip 2: Brush Up on Anatomical Terms

Selecting the proper code also requires you to know your anatomy of the GI tract. Here are some terms to keep in mind to clarify your coding:

Upper GI tract: This includes the esophagus, stomach, and duodenum
Stomach: Terms that refer to “gastric” are referring to the stomach
Small intestine: Also called the small bowel, this organ connects between the stomach and the colon and is made up of the following three sections:
Duodenum: The first section of the small intestine following the stomach and preceding the jejunum
Jejunum: The middle section of the small intestine following the duodenum and preceding the ileum
Ileum: The final section of the small intestine following the jejunum and preceding the colon

Endoscopy (also called enteroscopy) procedures relate to these anatomical terms, with an esophagoscopy involving just the esophagus, and an EGD involving the esophagus, stomach, and duodenum. Some procedures, such as push endoscopy, may also access the jejunum.

Distinguish colon: CPT^®provides similar pathology exam codes for polyps, biopsies, and resections from lower GI tract, which includes the colon (also called large bowel or large intestine) and anus. Don’t confuse these codes with descriptors for upper GI specimens.

Tip 3: Document Distinct Specimens

Your pathologist might receive multiple specimens from a single upper GI procedure, such as multiple polyps and/ or biopsies. How you code those cases will depend on the documentation and how well you understand the premise of anatomic pathology exam codes 88304-88309.

Key: CPT^®defines an anatomic pathology specimen as tissue(s) “submitted for individual and separate attention, requiring individual examination and pathologic diagnosis.”

“That means you should separately code each individually identified specimen,” says R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services in Jonesboro, Ark.

You’ll know you need to code pathology exam of more than one specimen if the documentation shows that the surgeon submitted multiple specimens that are individually identified by separate containers or a marker such as a suture and noted in the report. The pathology report should also identify the separate specimens, including gross and microscopic examination and diagnosis of each.

For instance: If the surgeon performs an EGD and submits one polyp from the stomach and one polyp from the duodenum, you should list the pathology service as 88305 x 2. If the surgeon does not distinguish the polyps, the pathologist will process them as a single specimen and you would code one unit of 88305. The pay difference between the two scenarios is $71.53 (Medicare Physician Fee Schedule 2021 national facility amount, conversion factor 34.8931).