Pathology/Lab Coding Alert

Focus on specimen to make the ‘margin’ call.

Everyone’s scared of “unbundling” and facing fraud charges, but don’t let that stop you from garnering legitimate pay for a separate margin exam in a breast case. 

Look at the following example and you make the call. Then we’ll walk you through the how and why of coding this case.

Partial Mastectomy Case

The pathology report includes the following specimens, services, and diagnoses:

Clinical history: Invasive ductal carcinoma right breast (diagnosis from previous biopsy), 46 year-old female patient (not Medicare).

Procedure: Segmental mastectomy, upper inner quadrant, right breast

Received is a pie-shaped portion of tan tissue measuring 9x6x5 cm. Orientation identified by medial, lateral, proximal and posterior margins. The surgical margins are inked. Focal mass measuring 3x2 cm identified grossly abutting posterior margin. Identified as specimen A, processed in five cassettes labeled A-1 through A-5. Examined additional immunohistochemistry (IHC) qualitative stains on five sections from block A-5, posterior margin for estrogen receptor (ER), progesterone receptor (PR) and Her-2/neu. 

Additionally received is a piece of tan tissue measuring 2x3x1 cm, identified as posterior margin. The surgical margins are inked. Identified as specimen B, sectioned and totally submitted.

Diagnosis:

Specimen A: Invasive ductal carcinoma, posterior margin positive. ER/PR Her-2/neu negative.

Specimen B: Invasive ductal carcinoma, margins clear

Check Your Code Choices Here

After you take a moment to decide how you would assign both the diagnosis and procedure codes for this case, look at our experts’ advice below and see how you did.

Specimen A: 

Diagnosis: Invasive ductal carcinoma (IDC): 174.2 (Malignant neoplasm of upper-inner quadrant of female breast), estrogen receptor negative: V86.1 (Estrogen receptor negative status [ER-]). 

ICD-9 doesn’t provide a specific code for PR or Her-2/neu status, so you should simply report the ICD-9 code for the breast cancer and any ER status findings, according to Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M.

Procedure: Report the partial mastectomy specimen exam as 88307 (Level V - Surgical pathology, gross and microscopic examination, Breast, excision of lesion, requiring microscopic evaluation of surgical margins Breast, mastectomy - partial/simple). 

For the ER/PR and Her-2 neu IHC stains, report three units of 88342 (Immunohistochemistry or immunocytochemistry, each separately identifiable antibody per block, cytologic preparation, or hematologic smear; first separately identifiable antibody per slide). 

Although 88342 now allows you to code per block, the pathologist examined IHC stained slides only from one block of the 88307 specimen. You should report three units because the pathologist evaluated three unique antibodies on separate slides. 

Specimen B:

Diagnosis: Invasive ductal carcinoma (IDC): 174.2 (Malignant neoplasm of upper-inner quadrant of female breast)

Procedure: 88307 (…Breast, excision of lesion, requiring microscopic evaluation of surgical margins).

“Because the partial mastectomy specimen includes margin exam, you might be hesitant to separately report the additional proximal margin,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark. 

Key: But you can bill for two specimens, because the surgeon separately identified the proximal margin and submitted it for individual attention in addition to the partial mastectomy. Further, the pathologist separately processed and evaluated the partial mastectomy as one specimen and the proximal margin as a separate specimen.

Because the pathologist examined the posterior margin as a distinct lesion excision, including margin exam, the service warrants an 88307 charge. 

“If the work to examine the posterior margin re-excision doesn’t measure up to the complexity of an 88307 exam, we would report 88305 (Breast, biopsy, not requiring microscopic evaluation of surgical margins) for the additional specimen,” Stainton says.

Don’t lose: If you had bundled the posterior margin exam into the partial mastectomy and failed to charge for it, you could cost your practice $288. That’s the value of an 88307 exam on the Medicare Physician Fee Schedule (national facility amount, conversion factor: 35.8228