Pathology/Lab Coding Alert

Skip reporting pre-op diagnosis.

When your pathologist examines and diagnoses multiple GI specimens from the same patient, you face several coding traps that could sacrifice the pay you deserve.

Study the following case, then check out our expert’s analysis of how you should assign the procedure and diagnosis codes.

Appraise the Case

The surgeon performed a colonoscopy and an esophagogastroduodenoscopy (EGD) for a patient with severe iron-deficiency anemia to rule out internal bleeding and malabsorption in the GI tract. The surgeon noted a large hiatal hernia with bleeding, linear lesions at the neck of the hernia.

Specimens: The pathologist receives the following:

A. Z-line biopsy
B. Duodenum tissue
C. Polyp from ascending colon
D. Grade 1 hemorrhoids

Diagnosis: The pathology report documents the following for each specimen:

A. 8 mm of erythematous, eroded mucosal tissue from gastroesophageal junction. Noted histopathologic changes of interstitial congestion and mucosal degeneration consistent with ischemia: Cameron erosions
B. 6 mm duodenum biopsy with mild inflammation. Visualized five elongated villi with submucosal Brunner’s glands. Villous to crypt ratio 4:1, PAS stain negative: Normal duodenal tissue.
C. 1.3 cm polyp, with low grade dysplasia, 20 percent villous component: Tubular adenoma
D. 3.2 cm thick-walled, congested submucosal vessel. Noted transitional mucosa with papillary endothelial hyperplasia: Internal hemorrhoid.

Assign EGD-Specimen Codes

You can identify which of the four listed specimens are from the upper GI endoscope based on anatomic site. Because an EGD accesses the patient from the esophagus to the duodenum, you should recognize two distinct biopsy specimens listed as A and B.

Trap 1: Specimen A is from the gastro-esophageal junction, and the pathologic description is consistent with gastric ischemic gastritis, which would lead to different coding.

Based on the microscopic evidence and the surgeon’s documentation of a large hiatal hernia associated with linear lesions, the pathologist diagnosed Cameron erosions, which are a type of gastric ulcer. Assign diagnosis code K25.4 (Chronic or unspecified gastric ulcer with hemorrhage). Assign the procedure code for specimen A as a gastric biopsy, 88305 (Level IV - Surgical pathology, gross and microscopic examination, … Stomach, biopsy …).

Specimen B is a duodenum biopsy demonstrating mild inflammation, which codes to K52.9 (Noninfective gastroenteritis and colitis, unspecified). The specimen is a duodenum biopsy, so the correct procedure code is 88305 (… Duodenum, biopsy…).

Trap 2: Don’t miss coding for the special stain. “The report documents a Periodic acid Schiff (PAS) stain, which pathologists may use for duodenum biopsies to identify possible microorganisms such as H pylori,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark. Code the PAS stain as 88312 (Special stain including interpretation and report; Group I for microorganisms (eg, acid fast, methenamine silver)).

Focus Colonoscopy-Specimen Codes

Based on anatomic site, you can see that specimens D and C are from the colonoscopy. The correct procedure code for the pathology exam of specimen C is 88305 (… Polyp, colorectal…).

Trap 3: The pathologist’s diagnosis for the colonic polyp is tubular adenoma. But if you choose K63.5 (Polyp of colon) for the diagnosis code, you will be wrong. Looking at the Excludes1 note under K63.5, you’ll see that the code does not describe an adenomatous polyp. Tubular adenoma is an adenomatous polyp, so you should report the diagnosis as D12.6 (Benign neoplasm of colon, unspecified).

For specimen D, you should report procedure code 88304 (Level III - Surgical pathology, gross and microscopic examination, … hemorrhoids …).

The correct diagnosis code is K64.0 (First degree hemorrhoids). The surgeon identified the hemorrhoid as grade 1, meaning that it is an internal hemorrhoid that doesn’t prolapse. The description under K64.0 includes grade/stage 1 hemorrhoids.

Final Tally

Your final procedure coding for the case should be 88305 x 3, 88304, and 88312. Although the pathology report includes a diagnosis for each specimen, the diagnosis code most significant for the patient’s condition and the reason for the test is the Cameron erosions, K25.4. These entities are often associated with gastrointestinal bleeding and anemia.