Pathology/Lab Coding Alert

Avoid pitfalls at each pathology exam stage.

When a patient advances through multiple diagnostic and treatment steps for breast cancer, your pathologist might perform a host of procedures.

Let our experts lead you through one case in point -- from initial patient complaint to definitive diagnosis -- so you can learn how to capture all the pay your pathologist deserves.

Phase 1: List 1 FNA for 2 Cytology

Scenario: Patient presents at physician office with a lump in her right breast (upper inner quadrant). The treating physician sends the patient for a mammogram. Suspecting ductal carcinoma in situ (DCIS) based on the findings, the radiololgist extracts a fine needle aspiration (FNA) specimen and sends it to the pathologist for interpretation.

The pathologist examines the FNA specimen using Pap staining of direct and concentrated smears, and confirms cellular changes consistent with pre-invasive cancerous changes of DCIS.

Solution: Because the pathologist did not perform the FNA extraction or an immediate check for specimen adequacy, "the only FNA code you can report for the pathologist's service in this example is 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report)," says R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.

Pitfall: The path report documents direct and concentrated smears from the FNA cytology specimen, but that doesn't mean you can additionally report cytology codes such as 88104 (Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation) and 88108 (Cytopathology, concentration technique, smears and interpretation [e.g., Saccomanno technique]). "Code 88173 includes interpretation of all slides examined from the FNA, regardless of slide preparation method," cautions Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M.

Diagnosis: Because the pathology findings are consistent with the initial diagnosis of DCIS, you should report ICD-9 code 233.0 (Carcinoma in situ of breast).

Phase 2: Add-Up Intraoperative Consult Services

Scenario: The treating physician schedules the patient for a lumpectomy. During the procedure, the surgeon finds that the tumor is not confined to the lactiferous ducts.

The pathologist goes to surgery to render an intraoperative consult. The surgeon shows the pathologist the lumpectomy specimen, pointing out the long and short sutures that mark the medial and lateral margins of the specimen. In addition to providing an intraoperative diagnosis, the surgeon asks the pathologist to evaluate the marked margins in particular due to concern that they may show residual tumor.

The pathologist performs a rapid microscopic examination of the lumpectomy specimen using frozen section technique (one block) and jots down her immediate diagnosis, which is "infiltrating ductal carcinoma." She then performs touch preps on each of the two resection margins that the surgeon marked and jots down her findings: "medial margin: no tumor present; lateral margin: no tumor present" and reports her findings to the surgeon.

Based on the pathology report of clear margins and carcinoma, the surgeon proceeds to perform a sentinel lymph node biopsy to rule out metastatic disease, and to close the surgical wound.

Solution: You can separately code three sites/services that the pathologist performs in phase 2: the frozen block for tumor diagnosis, plus the separately marked medial and lateral resection margins. "Each site is medically significant to the patient's care and treatment. Neither touch preparation exam in any way duplicates the frozen section exam," Stainton explains.

You should report the case as 88331 (Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen) for the frozen section for the intraoperative tumor diagnosis.

Plus touch prep: You can also report two intraoperative touch preps, because you have documentation that they're from two different sites distinct from the frozen section. List +88334 x 2 (Pathology consultation during surgery; cytologic examination [e.g., touch prep, squash prep], each additional site [List separately in addition to code for primary procedure]) for the two distinct margin touch preps.

Pitfall: If the patient's insurer is Medicare or another payer that utilizes Correct Coding Initiative (CCI) edits, you'll need to append modifier 59 (Distinct procedural service) to +88334. That's because CCI bundles +88334 as a column 2 code with 88331 for the same site, but allows you to override the edit pair for distinct sites.

Phase 3: Capture Multiple Surgical Pathology Exams

Scenario: The lab processes the lumpectomy specimen as three 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 lumpectomy specimen as infiltrating ductal carcinoma, margins clear.

The lab also processes the sentinel lymph node biopsy, preparing two blocks, cutting four levels from each block, and performing S100 staining on three to six slides from each level. The pathologist examines the multiple immuno-stained slides from each level of each block and notes no metastasis.

Solution: For the pathologist's lumpectomy exam, you should report 88307 (Level V -- Surgical pathology, gross and microscopic examination, breast, mastectomy - partial/simple). According to CPT® definition, a lumpectomy is equivalent to a partial mastectomy, so margin evaluation is not a "condition" of selecting 88307 for the service.

"You should list one unit of 88307 for the lumpectomy exam, regardless of the number of blocks and slides," Stainton says.

Sentinel node is separate: Report an additional unit of 88307 (... sentinel lymph node) for the sentinel lymph node exam.

Pitfall: You can't bill the special stain per slide, per level, or even per block. Despite preparing and examining approximately 20 S100 slides, you can bill only one unit of 88342 (Immunohistochemistry [including tissue immunoperoxidase], each antibody). "You should report an immunohistochemistry (IHC) stain once per antibody per specimen," Stainton says.

Diagnosis: Code the infiltrating ductal carcinoma as 174.2 (Malignant neoplasm of upper-inner quadrant of female breast).