Pathology/Lab Coding Alert

Let our experts' scenarios show the way for macrodissection billing.

Wondering when your pathologists' tissue prep services warrant reporting 88387-+88388 (Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies [e.g., nucleic acid-based molecular studies]...)?

You read the primer for these codes in Pathology/Lab Coding Alert's Vol. 11 No. 4 "Garner Molecular Studies Preparation Pay -- Here's How." Now you can study the following scenarios to get an idea of services that would merit 88387 or +88388 pay.

Tackle This Lymph Node Scenario

"The most common specimen we might process using methods described by 88387-+88388 is a lymph node," says Sophia Hauxwell, MT-ASCP, laboratory scientist in the University of Nebraska Medical Center Molecular Diagnostics Laboratory in Omaha. That's also the specimen that CPT lists as an example for these codes.

Sample case: During a quadrantectomy procedure, the surgeon requests a pathology consultation on sentinel lymph node(s) to determine the potential need for a lymphadenectomy. The physician also wants a molecular diagnostics B-cell and T-cell clonality check for malignancy.

The pathologist receives the sentinel lymph node(s) and proceeds with sterile technique to avoid nodal contamination that could compromise findings from molecular diagnosticstesting. The pathologist identifies a 1.5-cm lymph node and teases it out of the surrounding fatty tissue. He also finds a 1-cm lymph node and dissects it out separately.

The pathologist proceeds to process each lymph node, keeping them separate and sterile to avoid cross contamination that could lead to false positive results. He carefully cuts thin sections from each node to submit for T-cell and B-cell clonality testing.

Finally, the pathologist freezes the remaining nodal tissue, preparing one block from each node, and examines frozen sections to provide diagnostic findings to the surgeon in the operating room.

Bill these codes: For the frozen section examination and report during surgery, you should list two units of 88331 (Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen).

"Because the pathologist examines frozen sections from tissue blocks prepared from two unique sentinel nodes, you should code 88331 x 2 instead of 88331 plus 88332 (... each additional tissue block with frozen section[s])," explains Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

Note that the pathologist does not follow typical frozen section protocol during the initial macroscopic specimen exam. Instead, he proceeds with sterile technique and careful dissection and tissue thin-sectioning for molecular diagnostics test preparation. That means you can report two units of +88388 (... in conjunction with a touch imprint, intraoperative consultation, or frozen section, each tissue preparation [e.g.,single lymph node] [list separately in addition to code fro primary procedure]).

Add the molecular tests: If you perform the molecular diagnostics testing in your lab for B-cell and T-cell clonality screening assay by polymerase chain reaction (PCR), the coding might look something like this, depending on the test specifics:

83891 -- Molecular diagnostics; isolation or extraction of highly purified nucleic acid, each nucleic acid type (i.e., DNA or RNA)

83898 x 12 -- ... amplification, target, each nucleic acid sequence

83894 x 3 -- ... separation by gel electrophoresis (e.g., agarose, polyacrylamide), each nucleic acid preparation

83896 x 3 -- ... nucleic acid probe, each

83909 -- ... separation and identification by high resolution technique (e.g., capillary electrophoresis), each nucleic acid preparation

83912 -- ... interpretation and report.

Take On This Soft-Tissue Tumor Example

"Soft-tissue tumor is another specimen that we might see processed for molecular diagnostics testing using special tissue preparation techniques," Hauxwell says.

Scenario: The pathologist receives a soft-tissue tumor that the surgeon submits from a simple excision procedure. The patient is a five-year-old child with a painful neck mass.

During the gross exam, the pathologist identifies a portion of the tissue for molecular diagnostics testing. Using sterile technique to avoid contamination, the pathologist prepares thin sections of representative portions of the tumor for rhabdomyosarcoma tumor-marker testing.

The molecular test involves isolation and reverse transcription of patient RNA, polymerase chain reaction (PCR) amplification using primers for PAX3, PAX7, and FKHR genes on chromosome 13q14, and fluorescence probe analysis.

The pathologist proceeds to submit the remainder of the fresh tissue for paraffin embedding and slide preparation with Hematoxylin and Eosin (H&E) staining. The pathologist examines the sections under the light microscope and submits a report on the findings.

Code this: List the pathologist's evaluation and report on the soft-tissue tumor as 88307 (Level V -- Surgical pathology, gross and microscopic examination, soft-tissue mass [except lipoma], -- biopsy/simple excision).

For the macroscopic tissue examination and preparation for molecular diagnostics testing, report 88387 (...each tissue preparation [e.g., a single lymph node]).

You can only use this code when documentation shows that the pathologist conducts the work under sterile conditions, and that it is distinct from the usual macroscopic examination of the main portion of the tissue specimen that goes to histology for paraffin embedding and routine stained-slide preparation, according to Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., publisher of the Pathology Service Coding Handbook, in The Villages, Fla.

List molecular codes: Don't forget to list the molecular diagnostics procedures if you perform those tests instead of sending out the specimen. For the PAX3, PAX7, and FKHR molecular diagnostics analysis, your coding would look something like this, depending on the exact lab procedures: 83891, 83902 (... reverse transcription), 83898 x 3, 83896 x 3, and 83912.