Pathology/Lab Coding Alert

Hint: Capture separate specimens to boost your bottom line

If your pathologist examines a complicated endometrial cancer 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 This Case Note

Diagnosis: Adenocarcinoma of the endometrium with metastatic involvement of omentum.

Operation performed: Hysterectomy with bilateral salpingo-oophorectomy, pelvic and periaortic node dissection, partial omentectomy.

Procedure: The surgeon removed the uterus with fallopian tubes and ovaries, and the pathologist was present to open the organ and render an opinion.

The pathologist reported an enlarged, fungating, relatively superficial lesion of the endometrium. Up in the patient's right fundal area, however, the pathologist noted an invasion of the myometrium at least two-thirds of the way through. He examined two frozen section blocks from the fundus. Based on the pathologist's observations, the surgeon performed a partial omentectomy and bilateral pelvic (iliac) node dissection. The surgeon also obtained tissue in the periaortic lymphatic chain area, and the pathologist examined a frozen section from one of the lymph nodes.

Coding Challenge 1: Capture Intraoperative Service

The first thing you must do is decide what to charge for the pathologist's intraoperative service. When you read the description, notice that the pathologist provides a consultation based on gross examination, and also examines three frozen section blocks. Hint: Watch out for Correct Coding Initiative (CCI) edits when you select the code(s), says R.M. Stainton Jr., MD, president of Doctors- Anatomic Pathology Services in Jonesboro, Ark.

Answer: The pathologist performs intraoperative frozen sections. For the first block from the fundus, you should report 88331 (Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen) and the second slide as 88332 (- each additional tissue block with frozen section[s]). For the frozen section from the lymph node, you should report an additional unit of 88331, Stainton says. 

Avoid this pitfall: Although the pathologist provides a consultation based on gross exam of the specimen, you should not additionally report 88329 (Pathology consultation during surgery). CCI edits bundle 88329 with 88331 and 88332 because the frozen sections include the consultation service.

Coding Challenge 2: Define Separate Specimens

The pathologist examines the uterus, omentum, and fallopian tubes and ovaries (and lymph nodes, but we-ll look at those in challenge 3). Hint: You must consider bundling rules as you identify which tissues constitute separate specimens. -You also have to consider that the adenocarcinoma diagnosis will impact your code selection for uterus,- Stainton says.

Answer: The op report lists hysterectomy and bilateral salpingo-oophorectomy en bloc, so you can't report them as separate specimens. CPT bundles tubes and ovaries with the uterus in an instance like this, Stainton says. The proper code for the single specimen is 88309 (Level VI--Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, neoplastic). Because the specimen is cancerous, you would not choose 88307 (Level V--Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, other than neoplastic/prolapse).

Opportunity: Because the surgeon performs and submits for pathological examination a separate, partial omentectomy, you can code for a separate service. CPT does not list partial or total omentum resection as a surgical pathology specimen, so you have to select the code based on the level of work.

-Many pathology groups adopt a standard that the work for examining an omentum resection for tumor is equivalent to that of other Level-VI (88309) specimens,- says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., a pathology business practices publishing company in Simpsonville, Ky. In this case, you can report 88309 for the pathologist's exam for tumor of the separate omentum resection.

Coding Challenge 3: Clarify Lymph Coding

The pathologist examines lymph nodes from the pelvic and periaortic regions, so you-ll need to decide what constitutes separate specimens. Hint: Based on CPT definition or coding convention, sometimes you should bundle lymph nodes with surgical pathology specimens, but sometimes you should code them separately.

Answer: When CPT definition includes lymph nodes, such as some breast specimens (88309, - breast, mastectomy--with regional lymph nodes), you know you can't separately report the lymph nodes. But you have to bundle lymph nodes with some other specimens, even though the definition doesn't say so. You should not separately report lymph nodes that are -part of the resected 88309 specimen,- according to CPT Assistant Fall 1993. Based on this coding principle, a hysterectomy specimen does not ordinarily include lymph nodes, therefore you do not have to bundle them, Padget says.

Next step: Once you-ve settled that you can separately report the lymph node resections in this case, you have to decide how many resections you have. The pathologist examines left and right iliac lymph node resections, as well as periaortic lymph nodes.

For the lymph node resections in this case, you should report 88307 x 3 (- lymph nodes, regional resection),  Padget says. -Each separate lymph node resection warrants a single unit of 88307,- he says.