Look for surgical procedure clues. You could stand to lose $221 if you make the wrong call about how to report your pathologist’s tissue exam from a cervical loop electrocautery excisional procedure (LEEP). Check out the following case along with our expert’s advice to see how you can choose the correct cervical LEEP pathology exam code with confidence. Study The Case Details Look at the following information provided by the surgeon and the pathologist to help you assign the appropriate procedure codes: Clinical background: The 46-year-old patient who has been in perimenopause presents with irregular bleeding and pain. The physician orders lab tests for total estradiol, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and progesterone to help determine the patient’s menopausal status. These tests are common for potentially menopausal women who may have premature ovarian failure or who are being evaluated for risk of other health problems, according to Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico.
Preoperative diagnosis: Based on the lab results and clinical findings, the physician assigns a diagnosis of N95.0 (Postmenopausal bleeding) and schedules a colposcopy. Surgical procedure: During the colposcopy, the physician notes an abnormal lesion and applies local anesthetic before using an appropriately sized loop electrode to excise the lesion on the ectocervix with adequate margins, submitting it in one container. The surgeon then uses a loop to remove a tissue cone including the involved portion of the transformation zone and the endocervix, submitting the tissue in a second container. Specimen A: The pathologist grossly identifies the cone shaped ectocervix specimen, dividing the tissue into quadrants and processing tissue into three cassettes for hematoxylin and eosin (H&E) slide preparation. The pathologist documents microscopic examination of margins as clear, and assigns a diagnosis of “LEEP cervical conization: low-grade squamous intraepithelial lesion (LSIL).” Specimen B: The pathologist grossly identifies the cervical LEEP specimen in the second container, processing the tissue into four cassettes for H&E slide preparation of the endocervix and transformation zone. The pathologist describes normal columnar cells of the endocervix, and nonkeratinizing squamous metaplasia of the transformation zone, with normal margins. The assigned diagnosis is “LEEP cervical conization: endocervical and squamous metaplastic cells present.” Capture Pay for Each Service The first service you need to capture is the lab tests, if performed by your lab. You may use the following codes to describe the testing: Tissue exam: The real challenge in this case is how to report the pathology evaluation. A LEEP specimen may be a biopsy or a conization, but you’d bill those with different codes, as follows: That means you need to ensure that the documentation clarifies the distinction between biopsy and conization. Look for these items to help you find the details that differentiate the two: Specimen count: You also need to justify whether the case supports billing one or two pathology exam procedures. “Receiving multiple specimens from a cervical LEEP procedure is not uncommon,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Arkansas. The surgeon in this case submits two specimens in two separate containers. The pathologist separately evaluates and diagnoses the two specimens. That means you should bill a separate pathology exam for each specimen — two, in this case. Caveat: Multiple cervical LEEP specimens are not necessarily conization specimens. The pathologist might receive two (or more) LEEP biopsies, two (or more) LEEP conizations, or a combination of the two specimen types. Bottom line: The documentation in this case supports billing two distinct LEEP conization specimen exams. That’s 88307 x 2. Fees: With payment for 88305 at $71.84 and payment for 88307 at $292.79 (Medicare Physician Fee Schedule [MPFS] national facility amount, conversion factor [CF] 33.8872), you can see that inadequate documentation could cost you plenty. You stand to lose $220.95 for billing the initial LEEP conization as a biopsy, or $292.79 for missing the second specimen altogether.