Pathology/Lab Coding Alert

Use final diagnosis to snag additional pay.

You may think that coding the pathology exam of a “hysterectomy for prolapse” is a piece of cake — but not so fast. You’d better read the pathology report carefully or you could leave significant money on the table.

The scenario: Your pathologist receives tissue from an abdominal hysterectomy for prolapse. He opens the intact uterus and performs a gross exam, noting a 5.2 x 3.0 x 3.2 cm tan fibrous mass suspended from the mucousal surface of the fundus into the uterine cavity. The pathologist proceeds with the microscopic exam, processing the uterus in the following cassettes: 

• Cassette 1-5: fundal mass suspicious for leiomyoma
• Cassette 6-7: anterior body of uterus
• Cassette 8: posterior body of uterus
• Cassette 9: anterior lower uterine segment
• Cassette 10: posterior lower uterine segment
• Cassette 11: anterior cervix
• Cassette 12: posterior cervix
• Cassette 13: left fallopian tube and ovary
• Cassette 14: right fallopian tube and ovary

The final diagnosis is pedunculated submucous fibroid (218.0, Submucous leiomyoma of uterus).

Capture the Fibroid to Maximize Pay

Normally you’d code a prolapsed uterus pathology exam as 88305 (Level IV - Surgical pathology, gross and microscopic examination,… Uterus, with or without tubes and ovaries, for prolapse …).

But before you leave it at that, you should look through the additional information in the pathology report. For instance, you should consider the final diagnosis, and you should look at the cassettes, which include tissue such as uterine sections, a fibrous mass, and tubes and ovaries. 

Consider this: “The key to properly coding this case is noting the final diagnosis,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark.

That piece of information alone is enough to change your code selection from 88305 to 88307 (Level V - Surgical pathology, gross and microscopic examination, …Uterus, with or without tubes and ovaries, other than neoplastic/prolapse), because the pathologist does not process the specimen as a normal prolapsed uterus, but performs a more extensive pathological examination and diagnosis described by the uterus specimen listed under 88307. 

Avoid this pitfall: Because ICD-9 classifies leiomyoma as a benign neoplasm, coders have been known to skip over 88307 for hysterectomy with fibroids to report 88309 (Level VI - Surgical pathology, gross and microscopic examination, …Uterus, with or without tubes and ovaries, neoplastic…). 

That’s wrong. Uterine leiomyomas are an exception to the rule that you should report 88309 for hysterectomy for neoplasm. The Dec. 2003 CPT® Assistant® states that “leiomyomas do not require the same degree of evaluation as other uterine neoplasms,” and therefore concludes that you should report 88307 for a pathology exam that yields a principal diagnosis of leiomyoma of uterus.

Bundle tubes and ovaries: As long as the pathology report shows no indication of distinct pathology in the right and left fallopian tubes and ovaries, you should not separately bill for that exam. The 88307 hysterectomy code definition states “with or without tubes and ovaries.” That leaves you with one unit of 88307 for this case.

Why it matters: If you missed the final uterine fibroid diagnosis in the pathology report and billed 88305 instead of 88307, your practice could lose $217.80 of legitimate pay, based on the 2014 Medicare physician fee schedule national payment amount for 88305 and 88307 using conversion factor 35.8228.

But if you erroneously billed 88309, you could be looking at fraud charges and a repayment requirement to the tune of $150.46 (based on the 2014 Medicare physician fee schedule national payment amount for 88307 versus 88309 using conversion factor 35.8228).