Pathology/Lab Coding Alert

Capture each specimen to boost your bottom line.

When your pathologist examines tissue from a complicated colon case, you might be surprised how easy it is to underreport services and therefore miss some pay you deserve.

Study the following case, then see what steps our pros recommend to tackle three coding challenges you’ll face.

Review The Case

The surgeon performed a colonoscopy and terminal ileoscopy to diagnose the cause of blood in the stool. The pathologist received the following tissue from the case, and provided the listed diagnoses.

Specimens: Pathologist receives the following:

A. Vascular lesion, descending colon — irregular fragment of tan-pink mucosal tissue measuring 0.2 cm
B. Two biopsies, each measuring approximately 0.5 sq. cm, from a large sessile polyp identified at the splenic flexure
C. Two polyps in one container: identified by the surgeon — “the larger polyp” from the transverse colon and “the smaller polyp” from the ascending colon
D. 0.7 cm irregular tissue fragment from terminal ileum diverticulum

Diagnosis:

A. Angiodysplasia of descending colon
B. Adenomatous tissue with high-grade dysplasia of splenic flexure.
C. Adenomatous polyp of transverse colon, mucosal polyp of ascending colon
D. Ileal diverticulum 

Challenge 1: Identify Distinct Biopsies

Although the listed specimens and the diagnoses identify only “two biopsies,” you can’t depend on that wording to decide the number of biopsy specimens you should report.

In fact, you shouldn’t code two biopsies for specimen B, which lists “two biopsies” in the description. “Because the report doesn’t individually distinguish the two biopsies of the large sessile polyp in any way, such as separate containers or with a mark indicating location, you should report the two biopsies of specimen B as one unit of 88305 (Level IV - Surgical pathology, gross and microscopic examination, Colon, biopsy),” says R.M. Stainton Jr., MD, president of Doctors- Anatomic Pathology Services in Jonesboro, Ark.

On the other hand, you should report specimen A as a biopsy, even though the specimen description and diagnosis don’t use the word “biopsy.” “This specimen is a small piece of colonic tissue that shows a vascular abnormality which may be responsible for bleeding,” Stainton says. The tissue is a colon biopsy, and you should report it as another unit of 88305.

Challenge 2: Distinguish Polyps

Unlike the biopsies listed in item B, you can bill for two specimens in item C. That’s because the surgeon distinctly identifies, and the pathologist separately examines and diagnoses, two distinct polyp specimens.

One polyp is from the transverse colon, and the pathologist diagnoses it as an adenomatous polyp. The second polyp is from the ascending colon, and the pathologist diagnosis it as a mucosal polyp.

Do this: “Report the pathology exam of the polyps listed in item C as two units of 88305 (… Polyp, colorectal),” Stainton says.

Challenge 3: Don’t Miss Diverticulum

You might be inclined to code item D as another colon biopsy, but you would be wrong.

First of all, the surgeon advanced the scope beyond the ileocecal valve to view the terminal ilium, which is part of the small intestine. Although the code is the same, the more accurate description of a biopsy specimen from this site would be 88305 (…small intestine, biopsy).

But the surgeon and pathologist identify the specimen as an ileal diverticulum, not as a biopsy of the small intestine. That means the most accurate code for the specimen is 88304 (Level III - Surgical pathology, gross and microscopic examination, Diverticulum - esophagus/small intestine).