Pathology/Lab Coding Alert

"Some of the confusion regarding appropriate coding for various bone sampling and evaluation procedures is removed when coders understand the difference between bone-marrow aspiration, bone-marrow biopsy and bone biopsy in terms of indications, procedures and types of specimen procured. Additionally, coders need to be familiar with the different codes for specimen collection, manipulation and evaluation, including the technical and professional components of each. With this understanding, pathologists and laboratories can better capture reimbursement for specimen sampling, preparation and pathologic examination. Practices also need to be aware of appropriate coding for adjunct procedures, such as cell blocks and special stains, so they will be reimbursed appropriately for those services as well.

Bone-marrow Biopsy

R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services , an independent pathology laboratory in Jonesboro, Ark., explains that bone-marrow biopsy often is used in the diagnosis of a host of diseases involving the bone marrow. The procedure may be ordered for primary neoplasia [cancers] such as myeloblastic leukemia [205.00] or acquired aplastic anemia [284.98] or metastatic disease with secondary bone-marrow involvement, he continues. Overall, it is an excellent tool for assessing cellularity [condition and degree of cells present] of bone marrow, he claims.

Bone-marrow biopsy is carried out through a small incision made over the biopsy site, typically the superior iliac spine. A needle or trocar is inserted through the cortex of the bone, and a core of marrow is removed. A pathologist or hematologist/oncologist often carries out this procedure. The appropriate CPT Code for the procedure is 85102 (bone marrow biopsy, needle or trocar).

Following the biopsy, typically, laboratory technicians prepare the bone-marrow tissue for examination by a pathologist. The basic slide preparation services for the bone-marrow specimen are considered bundled in the surgical pathology code used to report the service, 88305 (surgical pathology, gross and microscopic examination, bone marrow, biopsy). Preparing the tissue for examination comprises the technical component of the code and for Medicare and many third-party payers should be reported as 88305-TC (technical component) if the laboratory and the pathologist bill separately, advises Laurie Castillo, MA, CPC, president of the Northern Virginia Chapter of the American Academy of Professional Coders, and owner of Physician Coding & Compliance Consulting in Manassas, Va. You should check with the insurer involved, however, to determine if -TC is the appropriate modifier, she cautions.

In addition to the usual steps of specimen preparation, bone-marrow biopsy specimens typically require a separate step to remove calcium that is not considered a bundled service, Stainton informs. It is reported separately using CPT 88311 (decalcification procedure). This is an add-on code, meaning that it should be listed separately in addition to the code for surgical pathology examination (in this case, 88305).

Whether or not the pathologist removed the biopsy tissue, he or she will be involved in the examination and interpretation of the sample. If the examination is billed globally with the tissue preparation, the service is reported as 88305. If the pathologist bills only for the physician service, it should be billed as 88305-26 (professional component).

Finally, the bone-marrow specimen might be prepared with special stains that are reportable separately. For example, we might use a reticulum stain to better visualize the reticulum fibers in cases of myelodysplastic syndrome (238.7), says Stainton. This stain is reported using code 88313(special stains; group II, all other, [e.g., iron, trichrome] except immunocytochemistry and immunoperoxidase stains, each), which is an add-on code. There are a host of reasons for pathologists to use special stains for bone-marrow biopsy specimens, and each of the stains used should be reported with the appropriate code (88312-88314), he concludes.

Bone-marrow Aspiration

Bone-marrow aspiration is indicated for a lot of the same conditions as the bone-marrow biopsy, and in fact, the two specimens usually are taken together, reports Stainton. The bone-marrow aspirate reveals cytologic detail better than the bone-marrow biopsy, and the two specimens together can give a fuller picture of the patients condition, he continues.

The procedure for bone-marrow aspiration is similar to the biopsy. A needle is attached to a syringe to remove a small amount of fluid (cells) rather than intact tissue. Code 85095(bone marrow, aspiration only) is used to report this procedure, which often is carried out by the pathologist. If both a biopsy specimen and an aspirate are taken, often it is through the same incision.

That is why there is a Correct Coding Initiative (CCI) edit that prohibits listing these two procedures together for the same patient on the same day, warns Castillo. If both specimens are taken through the same incision, only the code for bone-marrow biopsy (85102) should be reported.
But if a bone-marrow biopsy (85102) and a bone-marrow aspiration (85095) are carried out at two different sites on the same patient on the same day, or at two separate patient encounters, both codes should be reported. In those cases, modifier -59(distinct procedural service) should be attached to the second procedure for Medicare reporting, she explains.

As with bone-marrow biopsy, there is a separate code for interpretation of the bone-marrow aspirate, says Stainton. Code 85097 (bone marrow; smear interpretation only, with or without differential cell count) is used to report this service and should be billed in addition to the code for sample collection and the code for bone-marrow biopsy interpretation, if those services also are provided.

Code 85097 applies whether the findings are reported descriptively or with a quantitative differential cell count. If the pathologist or lab provides both the technical services, such as staining, and the interpretation, 85097 should be reported without a modifier. If the pathologist provides professional interpretation only, modifier -26 should be used.

Usually after the smears are prepared, the remainder of the aspirate is processed as a cell block, reports Stainton. If a cell block is prepared and evaluated in the histology laboratory, an additional code of 88305 should be reported also.

As with bone-marrow biopsy, it is not uncommon for special stains to be used in the examination of bone-marrow aspirate. For example, Sudan black B or myeloperoxidase stains may be used to provide improved cellular detail when evaluating a leukemia patient as an aid to classifying the type of leukemia, reports Stainton. These stains would be reported using code 88342 (immunocytochemistry [including tissue immunoperoxidase], each antibody) in addition to the codes for other services provided.

Bone Biopsy

Bone biopsy is a surgical sampling of bone tissue other than the marrow. The indications for this test generally are different than for bone-marrow biopsy or aspiration. A bone biopsy typically is carried out for a primary bone disease, such as Pagets disease (731.0), or for a benign neoplasm of the bone (213.9) or for metastatic bone involvement (198.5), explains Stainton.

Like bone-marrow biopsy and aspiration, there are separate codes for taking the bone biopsy sample and for evaluating the biopsy, Castillo emphasizes. The codes for sampling the bone tissue are 20220-20251, based on how the specimen is taken (e.g., trocar or open surgical excision), as well as the location of the sample (e.g., sternum or thoracic vertebrae), she continues. According to Stainton, pathologists rarely carry out these procedures; rather, a surgeon or radiologist may do them.

The interpretation of a bone biopsy by the pathologist is reported as 88307 (surgical pathology, gross and microscopic examination; bone - biopsy/curettings). As with the bone-marrow biopsy, a decalcification usually is carried out, and reported with code 88311, in addition to 88307, clarifies Stainton.

Capture All Services Rendered

Accurate coding depends on an understanding of the different indications, procedures and samples involved in bone-marrow biopsy, bone-marrow aspiration and bone biopsy. Receiving appropriate reimbursement requires that coders report each step of the services provided, from sample collection, to laboratory manipulation (e.g., decalcification and special staining), to examination and interpretation, concludes Castillo.

Editors note: The ICD-9 codes used for this article are unspecified, as they are used for example only. Be sure to assign these codes to the highest level of certainty when coding for your pathologist."