Pathology/Lab Coding Alert

When surgical pathologists provide multiple margin-evaluation services for neoplasm, you need to capture each procedure for payment. Reporting a lower surgical pathology level or failing to report adjunct services could mean sacrificing legitimate payment.

"Not only can margin evaluation increase the surgical pathology examination level, it can also involve additional procedures," says R.M. Stainton, MD, president of Doctor's Anatomic Pathology in Jonesboro, Ark., which serves 12 hospitals and numerous physician offices in Arkansas and Missouri.

Surgical pathology services (88300-88309) involve gross and microscopic (except 88300) examination of a surgically removed tissue specimen. The codes represent ascending levels of work, and CPT may list the same tissue under multiple codes based on the extent of examination work involved. Factors such as the suspicion of neoplasm, and the need to evaluate surgical margins, affect the code selection for many tissues.

When the pathologist evaluates margins, the service sometimes warrants a higher surgical pathology level because the specimen may be neoplastic. "Margins aren't the reason for coding the higher level, but when coders see notes about margin evaluation in the pathology report, it should be a clue that the specimen is being evaluated for tumor," Stainton says. The notes may refer to "inked margins" and provide specific information, such as distance of tumor cells from the margin.

Breast tissue codes specifically differentiate whether the specimen requires margin evaluation: 88305 (Level IV - Surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins) and CPT 88307 (Level V - Surgical pathology, gross and microscopic examination, breast, excision of lesion, requiring microscopic evaluation of surgical margins).

Margin evaluation is also a factor when assigning the proper code level for other tissues that use terminology such as "neoplastic" or "for tumor." For example, stomach resection for tumor involves margin evaluation and is assigned a higher level (88309, Level VI - Surgical pathology, gross and microscopic examination, stomach - subtotal/total resection for tumor) than stomach resection for other causes (88307, & stomach - subtotal/total resection, other than for tumor). Similarly, colon resection for tumor requires margin evaluation (88309, & colon, segmental resection for tumor), while resection for conditions such as diverticulosis does not (88307, & colon, segmental resection, other than for tumor). Skin specimens also require margin evaluation only at the highest level of service, such as for squamous cell carcinoma or other neoplasms (88305, & skin, other than cyst/tag/debridement/plastic repair).

Evaluation of breast tissue provides some sticky coding scenarios involving margins. For example, the surgeon may perform a lumpectomy and, upon gross findings of tumor near the margin, sample additional margins. The pathologist receives a lumpectomy and three margins labeled anterior, superior and lateral. "Report this service as 88307 (& breast, excision of lesion, requiring microscopic evaluation of surgical margins) for the original lumpectomy and three units of 88305 (& breast, biopsy, not requiring microscopic evaluation of surgical margins) for each separately identified margin specimen," says Amy Tedesco, CPC, coding manager at DCL Medical Laboratories, which has two facilities serving hospitals and physicians in the Indianapolis and St. Louis regions.

A similar situation occurs with some colon resections, especially those involving newer methods that excise closer to the tumor to avoid patient colostomy. "In addition to the colon resection specimen [88309], the surgeon may separately submit colon donuts for individual tumor evaluation," Stainton says. In this case, the donut represents the true surgical margin. Because it's an unlisted specimen, you must assign the CPT code for colon donut based on the code "which most closely reflects the physician work involved when compared to other specimens assigned to that code," according to CPT.

"If the donuts are incidental to the resection, I'd consider them part of the original specimen and wouldn't charge for them. But if the surgeon specifically requests individual evaluation for tumor, I'd consider the donut similar to a colon biopsy and report 88305 (& colon, biopsy)," Stainton says.

Another difficult margin coding question involves breast re-excision specimens. If a surgeon excises a lesion suspicious for cancer, and the pathologic examination determines that the tumor extends close to one or more of the margins, the patient may return for a re-excision surgery within the following month. "The question arises whether the re-excision specimen constitutes 'excision of a lesion,' and I believe that it does," Stainton says. "Not knowing whether any tumor remains, the pathologist must carry out microscopic evaluation of margins of the re-excision, thus justifying code 88307 [& breast, excision of lesion, requiring microscopic evaluation of surgical margins]. Some of these re-excisions are quite large and may, in fact, be considered a quadrantectomy or partial mastectomy, which you'd also code as 88307 [... breast, mastectomy  partial/simple]."

 When a surgeon calls in a pathologist for an intra-operative consultation, you should report each frozen section in addition to the pathologist's evaluation of the surgical pathology specimen. For example, if a pathologist conducts frozen-section margin evaluation of a skin specimen and reports to the surgeon that the posterior margin is incompletely excised, you should code 88305 (& skin, other than cyst/tag/ debridement /plastic repair) for the skin evaluation and 88331 (Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen) for the frozen section.

If the surgeon subsequently excises an additional portion of the posterior margin and the pathologist consults and confirms clear margins, report an additional unit of 88305 for the second skin specimen and an additional unit of 88331 for the frozen section from the second skin specimen.

"Because the second frozen section is from a different specimen than the first, don't use 88332 [Pathology consultation during surgery; each additional tissue block with frozen section(s)]," Tedesco says. "Report 88332 only when the pathologist evaluates frozen sections from more than one tissue block from the same specimen."

For example, if a pathologist evaluates a frozen section of a lung wedge biopsy for immediate diagnosis, you should report 88331 for the frozen section, as well as 88307 (& lung, wedge biopsy) for the biopsy exam. If the surgeon then proceeds with a lobe resection and the pathologist consults on the margins of this new specimen, preparing three blocks for frozen sections, report 88309 (& lung  total/lobe/segment resection), 88331 for the frozen sections from the first block, and two units of 88332 for the frozen sections from the additional blocks, Tedesco says. Some carriers may require you to use modifier -59 (Distinct procedural service) to indicate that you are not unbundling but that the lung biopsy and resection are two separate specimens.

Don't Forget Margin Touch Preps

Pathologist's sometimes use "touch preps" for an intra-operative margin evaluation of a tumor resection, Stainton says. The method involves touching or crushing the excised tissue to a slide to remove cells for tumor evaluation. You should code a touch prep with 88161 (Cytopathology, smears, any other source; preparation, screening and interpretation). Report both the cytopathology service and the intraoperative interpretation (88329, Pathology consultation during surgery) in addition to the surgical pathology service when the pathologist uses touch preps for margin evaluation.

For example, a surgeon may perform a lumpectomy for a breast lesion and request a pathologist's determination of clear margins individually identified as to orientation. "The pathologist touches the multiple margins of the excised tissue to microscope slides and performs a cytological exam to determine if any cancer cells are present at the margins," Stainton says. The pathologist then informs the surgeon if re-excision is needed during the same operative session.

When evaluating touch preps from multiple margins individually identified on a single specimen, report multiple units of 88161, Stainton says. In this case, the touch prep, not the specimen, is the unit of service. The pathology report should include a diagnosis for each individually identified margin. Also report the pathologist's consultation service (88329) and the specimen evaluation (88307, & breast, excision of lesion, requiring microscopic evaluation of surgical margins).