Pathology/Lab Coding Alert

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:

• 82670 (Estradiol; total)
• 83001 (Gonadotropin; follicle stimulating hormone (FSH))
• 83002 (… luteinizing hormone (LH))
• 84144 (Progesterone)

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:

• 88305 (Level IV - Surgical pathology, gross and microscopic examination … Cervix, biopsy …)
• 88307 (Level V - Surgical pathology, gross and microscopic examination … Cervix, conization …)

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:

• A biopsy involves removing a small piece of tissue with no intention of removing an entire lesion, so a biopsy would not involve a margin exam.
• A conization specimen is larger, typically processed in three or more cassettes, and normally involves a margin exam.
• The ordering clinician should designate the specimen based on the surgical procedure — the two LEEP code choices are 57460 (Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix) or 57461 (… with loop electrode conization of the cervix)
• If the surgeon doesn’t clearly state the specimen, the pathologist determines the level of work involved to make the determination. Either way, the pathologist should indicate the choice in the diagnosis, or possibly as a comment in the gross description, clarifying whether the specimen is a biopsy or conization.

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.