Pathology/Lab Coding Alert

Answer 3 questions to pick the right code every time

 What's your pathologist examining -- cervix or endometrium, conization or curetting, neoplasm or prolapse? The choices are numerous and so are the chances to pick the wrong code. That can cost you money -- so use the following queries to help you pick the proper surgical pathology level for uterine tissue.

1. What Part of the Uterus Is It?

Even excluding fallopian tubes, ovaries and vagina, CPT lists as a specimen six -parts- or growths of the uterus that your pathologist might receive: cervix, endocervix, endometrium, uterus, polyp or leiomyoma. Finding the name of the tissue and linking it to a CPT listed specimen is the first step to finding the right code.
 
Pitfall: But that's not always easy because the surgeon or pathologist might use a different term than CPT, says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., a pathology business practices publishing company in Simpsonville, Ky. 
 
For instance, other terms that might appear in the report that mean the same thing as leiomyoma include fibroid, fibromyoma, myoma or leiomyofibroma. -If you see any of these names and the pathologist did not examine the entire uterus but just looked at the excised leiomyoma, you should code 88305 [Level IV -- Surgical pathology, gross and microscopic examination, leiomyoma(s), uterine myomectomy -- without uterus],- Padget says.
 
Don't miss: You might find uterine specimens in the pathology report that are not listed in CPT, such as cervical cyst. That's when you-ll have to select the code based on the level of work for a comparable specimen. For instance, coding for a cervical cyst is similar to a cervical biopsy (88305), Padget says.
 
See Clip-and-Save Chart: Match Pathology Report Keywords to Uterus Codes on page 59 to help you identify keywords, synonyms or unlisted specimens you might see that will help you correlate the pathology report to listed CPT uterine specimens.
 
But even identifying the tissue type won't necessarily lead you to the proper code. After all, CPT lists uterus, with or without tubes and ovaries, under 88305, 88307 and 88309. That's why you also have to answer the following questions to pick the proper code:

2. What Type of Procedure Did the Surgeon Carry Out?

Once you-ve identified the part -- such as cervix or endometrium -- the next step to selecting the correct code is understanding the type of extraction the surgeon performed.
 
Watch for: The surgeon might carry out a hysterectomy, resecting the entire uterus with or without fallopian tubes and ovaries. Or the surgeon might perform a biopsy, curettage, conization or LEEP, or excise a polyp -- removing only a part of a specific tissue.
 
Biopsy: A biopsy involves cutting a sliver of tissue, often during a colposcopy procedure for uterine specimens. CPT lists biopsies of any part of the uterus as 88305 (Level IV -- Surgical pathology, gross and microscopic examination ...), including the cervix, endocervix and endometrium. Polyps and leiomyomas are also 88305.
 
Snag: The report you-re coding from might not use the same terms as CPT -- you might see the terms -myometrium- or -endometriosis- instead of -endometrium.- Again, the Clip-and-Save Chart on page 59 can help you identify other terms you might see in the pathology report and show you the appropriate surgical pathology service level.
 
Curettage: Curettage is a different procedure from biopsy because it involves scrapping rather than cutting uterine tissue, also often during colposcopy. CPT also lists uterine curettage specimens as 88305, whether from the endometrium or endocervix. But the pathology report you-re coding from might say -ECC for endocervical curettings- or -EMC for endometrial curettings- -- so you-ll need to recognize these common terms.
 
Conization: The distinction between a conization and a biopsy specimen can be a matter of documentation -- but at a difference of $81.10 between surgical pathology levels IV and V, you-ll want to be sure to capture the cervical conization pay when the pathologist performs that service (88307, Level V -- Surgical pathology, gross and microscopic examination, cervix, conization).
 
The specimen refers to a cone-shaped excision of cervical tissue for diagnostic study, conventionally taken with a scalpel, Padget says. -The pathologist sections the cone by quadrants, resulting in a more extensive dissection than a biopsy -- which is why CPT lists cervical conization as 88307 and cervical biopsy as 88305,- Padget says.
 
LEEP: Sometimes the surgeon excises cervical tissue using the loop electrocautery excisional procedure (LEEP). The specimen from a LEEP procedure could be a biopsy or a conization.
 
-If the surgical note does not clarify the intended specimen, the pathologist must determine the level of work involved in the tissue exam and document the specimen as a cone or biopsy and code accordingly,- Padget says. The pathologist can clarify the specimen for coding purposes by using terms such as -LEEP biopsy- or -LEEP conization- in the pathology report.
 
Tip: If the surgeon submits two or three separate cervical LEEP specimens, you should code each individually according to the work required -- either biopsy or conization. -Don't bundle the specimens into a single 88307 as though they are portions of a single conization,- Padget says.
 
Resection: Myomectomy is a resection that involves removing fibroids from the uterus without performing a
complete hysterectomy. CPT lists this specimen as 88305 (- Leiomyoma[s], uterine myomectomy  -- without uterus).
 
For a hysterectomy, the pathologist receives a single specimen of the entire uterus, usually with the attached fallopian tubes and ovaries. But your code selection would be the same even without the adnexa because the CPT uterine code definitions state, with or without tubes and ovaries. In some circumstances, you might need to separate uterus and ovary specimen coding, and these scenarios have been described at length in the April 2001 Pathology/Lab Coding Alert.
 
Even knowing the part of the uterus and the type of excision won't always lead you to the proper CPT code for uterine specimens. You have to answer one final question to get to the bottom of correct coding:

3. What's the Diagnosis/Finding?
 
Once you-ve identified the specimen as a hysterectomy, you still have three codes to choose from -- based on the diagnosis or findings. -CPT assigns a few tissues to different surgical pathology levels depending on whether the diagnosis is neoplastic,- says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.
 
The uterus is one of those tissues, with the specimen assigned to three different levels based on the diagnosis:
 - 88305 -- ... uterus, with or without tubes and ovaries, for prolapse
 - 88307 -- ... uterus, with or without tubes and ovaries, other than neoplastic/prolapse
 - 88309 -- Level VI -- Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, neoplastic.

For example: If the hysterectomy diagnosis is 618.1 (Uterine prolapse without mention of vaginal wall prolapse), you should report the pathologist's examination as 88305. But you should list a uterus with a diagnosis of endometriosis (617.0, Endometriosis of uterus) as 88307 because the specimen is non-neoplastic and not for prolapse. -However, if the pathologist diagnoses adenocarcinoma of the endometrium [182.0, Malignant neoplasm of the corpus uteri, except isthmus] based on the gross and microscopic examination, the coder should report 88309,- Slagle says.
 
You should also report 88309 if the pathologist examines the uterus for suspicion of tumor (based on a prior biopsy, for example) but finds no current cancer. Abnormal cellular changes indicative of neoplasia such as moderate or severe dysplasia also involve the work of 88309.
 
Exception: Although you should report 88309 whether the uterine neoplasia is malignant or benign, the AMA (CPT Assistant December 2003), the College of American Pathologists and CMS agree on one exception to the rule: leiomyoma. -Although ICD-9 classifies leiomyoma as a benign neoplasm, both the AMA and CAP agree that you should code a hysterectomy for leiomyoma as 88307,- Padget says.
 
Don't miss: The clinical findings and pathological diagnosis don't influence the code selection for biopsy, curetting, LEEP or conization specimens, Padget says.