Pathology/Lab Coding Alert

Missed specimen identification could cost you $210.

Coding for your pathologist’s breast cases may be simple, but that doesn’t always mean they’re easy. Let this seemingly straightforward example help you focus on the pitfalls and opportunities that lead to coding correctly and capturing all the pay you deserve.

The case: The surgeon submits a “breast lump, left lower inner quadrant.”

The lab processes the excised breast lump specimen as two blocks, preparing multiple hematoxylin and eosin (H&E) slides, including slides for lateral and medial margin evaluation. The pathologist examines slides from each block and diagnoses the breast lesion as infiltrating ductal carcinoma, margins clear.

Consider Clues for Procedure Code Choice

This report contains hints about the specimen from both the surgeon’s description and the pathologist’s noted work. You can use that evidence to define the specimen and therefore choose the correct procedure code.

Nix biopsy: One thing is clear no matter how you read the report — this is not a biopsy specimen, so you can rule out 88305 (Level IV - Surgical pathology, gross and microscopic examination … Breast, biopsy, not requiring microscopic evaluation of surgical margins…).

Here’s why: The surgeon states that the specimen is a breast lump, which indicates the surgeon’s intent to remove the entire lump, not just a small sample of it. “The pathologist documents a margin exam, which also indicates the specimen is not a biopsy,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark.

88307 two ways: That leaves you with two ways you can think of this as an 88307 (Level V - Surgical pathology, gross and microscopic examination…) specimen.

• Lumpectomy: If the surgeon removes a lump, you can think of this as a lumpectomy specimen, which translates in CPT^® parlance to a partial mastectomy, even without documentation of a margin exam. You’d report that pathology exam as 88307 (… Breast, mastectomy - partial/simple…).
• Lesion excision: Because the pathologist documents the margin exam, you could also code this case as 88307 (… Breast, excision of lesion, requiring microscopic evaluation of surgical margins …).

Because lumpectomy and breast lesion excision exams both report to 88307, this is a distinction without a difference in terms of choosing the correct code and maximizing ethical pay for your pathologist’s work.

Key: The Medicare Physician Fee Schedule payment amount for 88305 is $71.46, and for 88307 is $281.50, meaning that missing this code selection could cost your practice $210 (national non-facility global amount, conversion factor 36.0896).

Double Down on Diagnosis

The surgeon provides a clear description of the case presentation: breast lump of the left lower inner quadrant. “Some of the body system chapters in ICD-10 include symptoms related to that area, such as N60-N65 for breast,” notes Melanie Witt, RN, MA, an independent coding consultant in Guadalupita, N.M.

That might leave you tempted to report N63.24 (Unspecified lump in the left breast, lower inner quadrant) as the diagnosis for this case, but you would be wrong.

Findings: When coding a case, you should not code presenting symptoms if you have more specific findings that you can report as the final diagnosis. “You should complete diagnosis coding based on the pathology report, when possible,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, CA.

Do this: The pathologist diagnoses infiltrating ductal carcinoma, and the surgeon noted the location of the lump, so you should report the diagnosis as C50.312 (Malignant neoplasm of lower-inner quadrant of left female breast).

Code C50 identifies the pathologist’s findings as a malignant neoplasm of breast, but you must report the code to six characters rather than reporting an incomplete “truncated” code. The fourth character describes the site on the breast where the cancer is found, such as “3” for lower-inner quadrant. The fifth character defines “1” for female breast or “2” for male breast. Finally, the sixth character defines right (1), left (2), or unspecified (9) breast.