Pathology/Lab Coding Alert

Capture separate specimens to boost your bottom line.

If your pathologist examines a cervical colposcopy case, you might find yourself underreporting or running afoul of bundling rules.

Read the following case description, then see what steps our experts recommend to help you tackle three coding challenges it presents.

First, Read Over the Case Note

Diagnosis: Cervical intraepithelial neoplasia [CIN] grade III, with severe dysplasia.

Procedure: During colposcopy, the surgeon used a loop electrode to excise a lesion on the exocervix with adequate margins. She then performed a second loop electrode excision of the involved portion of the endocervix, followed by a curette sampling of the upper excision boundary to ensure complete removal of the dysplasia. Surgeon's procedure code: 57461 (Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix).

The pathologist examined specimens and assigned diagnoses as follows:

• Specimen A -- Exocervix loop electrocautery excisional procedure (LEEP) conization: CIN grade III, margins clear
• Specimen B -- Endocervix LEEP biopsy: CIN grade III with severe dysplasia
• Specimen C -- Endocervical curettage (ECC) of proximal margin: normal cells.

Coding Challenge 1: Distinguish 88305/88307 for LEEP

The first question you need to answer is whether the LEEP specimen is a biopsy or conization.

Hint: Depending on whether the tissue represents a biopsy or conization, you can assign a cervical LEEP specimen to one of two CPT codes, says R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.:

• 88305 -- Level IV - Surgical pathology, gross and microscopic examination, cervix, biopsy
• 88307 -- Level V - Surgical pathology, gross and microscopic examination, cervix, conization.

How do you choose? "If the surgeon identifies the LEEP specimen as a biopsy or conization, you should use that designation to help you choose the appropriate pathology code," says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

Look to surgical procedure code: If the surgeon doesn't use the term "biopsy" or "conization" in the op note, you can use the surgical procedure to help decipher the surgeon's intended specimen. For LEEP specimens taken during colposcopy, CPT assigns two surgical codes:

• 57460 -- Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy[s] of the cervix
• 57461 -- ... with loop electrode conization of the cervix

In this case, the surgeon assigned 57461, indicating conization. That means conization may be an appropriate specimen designation for the pathologist.

Caution: "Because LEEP is not a listed specimen, the pathologist must make the final determination if the tissue exam involves a level of work commiserate with 88305 or 88307 and assign the code accordingly," Stainton says.

Coding Challenge 2: Decide LEEP Units

The second question you need to answer is whether you should code for one LEEP specimen or two.

Tip: If the surgeon submits two separately identified LEEP specimens and pathologist separately examines and diagnoses each specimen, you should report two distinct procedure codes for the pathologist's work.

"Even if the specimens are two parts of the same lesion, you should not bundle the tissue into a single unit of 88307 as though the pathologist received a single LEEP conization," Stainton says.

Do this: Report the LEEP service in this case as 88307 and 88305. The surgeon submitted two separately identifiable LEEP specimens. Because the pathologist identified specimen A from the exocervix as a conization and specimen B from the endocervix as a biopsy, you should not report 88307 x 2 or 88305 x 2.

Pass audit with flying colors: The pathology report must separately identify the specimens, describe the pathologist's work for each specimen, and provide a separate diagnosis for each specimen. Because the pathologist must decide whether the work involved in each specimen is more like a cervical biopsy or surgical conization, the pathology report should document the decision by using the word(s) "cone,"  "conization," or "biopsy" to support the CPT code selection and avoid audit problems.

Payers may limit: Despite appropriate documentation, some payers have refused to pay for two cervical conization LEEP specimens (88307 x 2) on the same day. Know your payers' rules and be aware of citations that supports your coding, such as "Cracking the Code" in the July 1999 CAP Today.

Coding Challenge 3: Manage ECC Sample

The surgeon submitted an ECC of the proximal margin of the endocervical LEEP -- should you bundle the margin with the LEEP specimen?

Don't bundle ECC: "The ECC represents a unique specimen, separately submitted and diagnosed by the pathologist, so you should bill for the work using a separate procedure code." Stainton says.

Report the ECC exam as 88305 (Level IV - Surgical pathology, gross and microscopic examination, endocervix, curettings/biopsy).

Final coding for the case: 88305 x 2, 88307