Pathology/Lab Coding Alert

Whether you'll see Medicare pay for bone marrow and bone biopsy specimen extraction or evaluation depends on the four guidelines below. Beware: With Correct Coding Initiative (CCI) directives and a HCPCS twist, these guidelines will put your coding savvy to the test.

Because a bone marrow biopsy allows the pathologist to assess cellularity and a bone marrow aspiration can provide enhanced cytologic detail, taking both specimens from the same patient on the same day to enhance diagnosis is not unusual, according to R.M. Stainton Jr., MD, president of Doctor's Anatomic Pathology in Jonesboro, Ark.

Snag: Medicare and some other payers use the CCI edits to restrict how you bill for "sequenced" surgical procedures through the same incision. For bone marrow biopsy and aspiration, CCI bundles the following codes:

• 38220 -- Bone marrow; aspiration only

• 38221 -- ... biopsy, needle, or trocar.

Watch for "different": You may report 38220 and 38221 together, according to the CCI Policy Manual, if the physician performs the procedures under either of the following conditions:

• Different patient encounters

• Different sites, meaning "in different bones or two separate skin incisions over the same bone."  For CMS and other payers who use the CCI edits, if the two procedures meet one of the above listed criteria, you may override the edit by appending modifier 59 (Distinct procedural service) to 38220 and receive payment for both services, says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

Caution: In one study, the Office of Inspector General (OIG) found that coders inappropriately used modifier 59 more often with 38220/38221 than any other code pair (http://oig.hhs.gov/oei/reports/oei-03-02-00771.pdf).

Look to HCPCS for "same": Medicare indicates you shouldn't use modifier 59 to bill 38220 and 38221 together for a bone marrow biopsy and aspiration through the same incision. But that doesn't mean you have no recourse.

For sequenced procedures, you'll report 38221 for the biopsy as usual. Then you can also report the aspiration to Medicare using G0364 (Bone marrow aspiration performed with bone marrow biopsy through the same incision on the same date of service), says Joyce Matola, billing manager for The Center for Cancer and Hematologic Disease in New Jersey. Make sure your pathologists know that you need documentation of incisions and sites.

After a physician takes a bone marrow aspirate or biopsy, a pathologist will evaluate the specimen for disease processes.

Capture aspirate exam: To report a bone marrow aspiration pathology exam, use 85097 (Bone marrow, smear interpretation). "Code 85097 applies whether the pathologist reports the findings descriptively or with a quantitative differential cell count," Stainton explains. After preparing smears, pathologists often process the remaining aspirate as a cell block, Stainton says. If that's the case, you should report the cell block as 88305 (Level IV -- Surgical pathology, gross and microscopic examination, cell block, any source) in addition to 85097 for the aspirate smears.

Report biopsy evaluation: For examining a bone marrow biopsy specimen, you should report 88305 (...bone marrow, biopsy).

"If the pathologist examines both a bone marrow aspiration and a bone marrow biopsy, you should report 85097 and 88305 together," Stainton says. CCI does not restrict using these codes together. As long as the pathologist examines distinct specimens -- a tissue biopsy and a separate cytology aspirate specimen -- you can list both examination codes even if there was only one incision or patient encounter.

Double up 88305: Don't miss the cell block, if the pathologist examines it. For an exam of aspirate, cell block, and biopsy, you should code 85097, 88305 x 2.

CPT provides distinct codes for bone biopsy extraction. Pathologists rarely perform even the superficial procedure 20220 (Biopsy, bone, trocar, or needle; superficial [e.g., ilium, sternum, spinous process, ribs), but you need to be aware of CCI restrictions for 20220 and 38221.

Although CMS acknowledges that it may be "medically necessary to evaluate both bone structure and bone marrow," if you can do so "from a single biopsy, only one code (CPT code 38221 or 20220) should be reported for the surgical procedure."

CCI goes on to state, "If two separate biopsies are medically necessary, both may be reported appending modifier 59 to one of the codes."

Do this: If the patient has a medically necessary bone biopsy and bone marrow biopsy on the same day, correct coding is 38221 and 20220-59.

"We might get a bone biopsy to assess a primary bone disease or for metastatic involvement on the same date as a bone marrow biopsy," Stainton says. The code for bone biopsy examination is 88307 (Level V -- Surgical pathology, gross and microscopic examination, bone -- biopsy/curretings).

If the pathologist evaluates bone and bone marrow, you'll report the service one of two ways, depending on the circumstances:

1. If the pathologist receives one specimen, select only one code (88305 or 88307, as appropriate) "even if the report includes evaluation of both bone structure and bone marrow morphology," according to the CCI manual.

2. If the pathologist receives distinct bone marrow biopsy and bone biopsy specimens (from different sites or patient encounters), you can list both 88305 and 88307 with no modifier restrictions.