Pathology/Lab Coding Alert

Don’t miss add-ons and separate services.

Riddle: When is a pathologist not just a pathologist? Solution: When he’s also a surgeon/dermatologist for procedures such as Mohs micrographic surgery.

If your practice includes an outpatient clinic performing skin cancer excision and histologic evaluation and margin exam by a single physician, you’ll need to know how to use the following codes:

·         17311 — Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue blocks

·         +17312 — …each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure)

·         17313 — … of the trunk, arms, or legs; first stage, up to 5 tissue blocks

·         +17314 — … of the trunk, arms, or legs; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure)

·         +17315 — each additional block after the first 5 tissue blocks, any stage (List separately in addition to code for primary procedure)

Key: Mohs “requires the integration of an individual functioning in two separate and distinct capacities: surgeon and pathologist. If either of these responsibilities is delegated to another physician or other qualified health care professional who reports the services separately, these codes should not be reported,” according to CPT^® instruction.

Once you’ve determined that your physician is wearing both hats and you should be reporting Mohs codes, follow our experts’ tips to make sure you capture all the pay you deserve:

Tip 1: Identify the Lesion Location

You should choose the primary Mohs code based on the location of the lesion. Use 17313 for Mohs procedures involving skin cancer of the trunk, arms, or legs — unless the surgery directly involves muscle, cartilage, bone, tendon, major nerves or vessels.

In those cases, you should turn to 17311. That’s also the correct code for skin cancer of the head, neck, hands, feet, or genitalia.

Each of the codes 17311 and 17313 involves the “first stage, up to 5 tissue blocks.” You’ll need to read tip 2 to understand what that means.

Tip 2: Distinguish Stages, Blocks

Mohs is a treatment procedure for a patient with diagnosed skin cancer. As opposed to a “wide excision,” the goal of Mohs is to remove the entire lesion (ensure clear margins) while preserving healthy tissue, as much as possible. To accomplish this, the physician shaves or excises the lesion, then performs histology to ensure clear margins while the patient is still in surgery. The first shaving or excision of a single lesion is the first “stage.”

The physician will take the tissue from the first stage, map and divide the tumor into pieces, and embed each piece of tumor into an individual mounting medium, such as frozen blocks. Each of these pieces of separately embedded tissue from a single stage is a “block,” and the physician typically prepares a few blocks from a single stage.

Whether the physician continues to a second stage depends on the histologic findings. If the margins are clear, the procedure is complete. “One layer [stage] may be enough,” notes Pamela Biffle, CPC, CPC-P, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Texas.

On the other hand, if the physician finds tumor cells in the margins of any of the tissue blocks, he will go back and remove more tissue from the patient during the same operative session. Each time the physician excises more tissue from the same, you have another “stage” in the Mohs procedure.

Tip 3: Use the Add-Ons

For the second and each subsequent stage of a Mohs procedure, CPT provides add-on codes that you should use to capture the service. The two code choices for subsequent stages are +17312 and +17314.

Do this: Let the initial procedure code dictate which add-on code you should use for subsequent stages. If the initial service is 17311, you’ll use +17312 for each subsequent stage. If the initial service is 17313, you should use +17314 for each subsequent stage.

Hint: If the physician finds margins clear and returns to surgery to excise the first stage of a different lesion, you should not use +17312 or +17314. Instead, you should report an additional unit of 17311 or 17313, depending on the location of the second lesion.

Capture blocks: CPT^® provides one more add-on code in this series — +17315. Report this code for each additional block in any stage that involves more than five blocks. That means you might use +17315 in addition to an initial Mohs code (17311 or 17313), or in addition to a subsequent-stage add-on code (+17312 or +17314). You should report multiple units of +17315 if a single stage involves seven or more blocks, or if the initial stage and subsequent stage each involve more than five blocks.

Tip 4: Capture Other Services

If a pathologist performs other services the same day as a Mohs procedure, you should bill them separately.

For instance: If the pathologist examines frozen sections of a lesion biopsy that provides the initial cancer diagnosis that leads to the Mohs procedure, you can separately report the frozen sections as report 88331 (Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen), according to R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark. You should also report the biopsy exam as 88305 (Level IV - Surgical pathology, gross and microscopic examination, Skin, other than cyst/tag/debridement/plastic repair).

Because Correct Coding Initiative (CCI) bundles 88331 and 88305 with Mohs codes for the same specimen, you’ll need to append modifier 59 (Distinct procedural service) to 88331 and 88305 to indicate that you’re dealing with two separate specimens.

Watch special stains: Mohs codes include a routine frozen section stain such as hematoxylin and eosin or toluidine blue, according to CPT^®. But if the pathologist performs additional special stains on Mohs frozen sections, you can report 88314 (Special stain including interpretation and report; histochemical stain on frozen tissue block [List separately in addition to code for primary procedure]) with modifier 59.