Pathology/Lab Coding Alert

Get the code wrong for "sinus stripping" and you stand to lose nearly $43 in pay.

With only two CPT-listed nasal-tissue specimens, you're bound to encounter other terminology in your pathology reports. Follow these five steps to make sure you select the proper code and avoid under- or over-charging for your pathologist's service.

It's easy when the pathologist uses language that specifically aligns with CPT's nasal tissue specimen codes.

"When the pathology report clearly identifies the tissue as nasal polyps or nasal biopsy, you should select 88304 or 88305 accordingly," says R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.

CPT assigns two types of nasal tissue to surgical pathology codes as follows:

• 88304 -- Level III -- Surgical pathology, gross and microscopic examination, polyps, inflammatory -- nasal/sinusoidal

• 88305 -- Level IV -- Surgical pathology, gross and microscopic examination, nasal mucosa, biopsy.

Catch: You'll likely encounter other nasal specimens in pathology reports that aren't polyps or biopsies -- what then? Because Medicare's 2009 physician fee schedule pays $62.40 for 88304 and $105.31 for 88305 (based on the national nonfacility total global relative value units), you'll want to make sure you select the proper code to capture all the pay you deserve.

When the pathologist examines an unlisted specimen, you must assign the code that "most closely reflects the physician work involved when compared to other specimens assigned to that code," according to CPT instruction. That can lead to gray areas, but the following code assignments are not unusual among pathologists:

Turbinate -- Nasal turbinates are bony protrusions inside the nasal passage that help moderate airflow and allow surface area for filtering, warming, and humidifying inhaled air. Because a turbinate is bony tissue, the most appropriate CPT code for the specimen is 88304 (... bone fragment(s), other than pathologic fracture).

Septum -- The nasal septum is the bony and cartilaginous tissue that divides the nose into two nostrils. As with turbinates, the best CPT code for the septum specimen is 88304, because the specimen is similar to cartilage shavings or non-pathologic fracture bone fragments, according to Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., publisher of Pathology Service Coding Handbook, in The Villages, Fla.

Counterpoint: "I find that the septum is often unremarkable tissue that requires less work than a bone fragment specimen, so I'll report the service as 88302 (Level II -- Surgical pathology, gross and microscopic examination)," Stainton says.

You might encounter several unlisted sinus terms in a pathology report that you can code using the following guidance:

Sinus contents -- The material labeled "sinus contents" often consists of intermixed fragments of tissue, mucosa, bone, and/or cartilage, according to Padget. "You will typically report a single CPT code for this hybrid specimen, because there's seldom a viable basis for arguing that any one component warrants individual attention and diagnosis," Padget says. "Even though this is an unlisted specimen, the physician work is most similar to 88305 (... sinus, paranasal biopsy), according to advice from the AMA's CPT Information Services unit."

Ethmoid tissue -- "Ethmoid" refers to a spongy bone of the skull that separates the brain from the nasal cavity, or tissue related to that bone. "Pathologists often use the term 'ethmoid tissue' interchangeably with 'sinus contents,' and the hybrid bone/mucosal specimen earns 88305," Padget says.

Sinus strippings -- Also called "sinus mucosal strippings," the College of American Pathologists states that "88305 most accurately captures the work involved with these specimens" (CAP Today, Oct. 2001).

Don't let a common myth force nasal specimens into an artificial charge bundling rule. Although 88304's descriptor "inflammatory nasal polyps" is plural, you can bill multiple units for separately identified polyp specimens.

"An 's' added to the specimen name in the text does not indicate an exception to the general pathology coding principle that you should separately code each individually identified specimen," Padget says. "For nasal polyps, as with other plural listed specimens -- fingers, toes, hemorrhoids -- you should report one unit of the appropriate code for each specimen that the physician individually submits and the pathologist separately diagnoses."

Before capturing this added fee, check that you're not overcharging. "The responsible pathologist has to be able to distinguish nasal specimens by some viable means, such as separate containers or histological characteristics, to separately diagnose and charge for separate specimens," Padget cautions.

Don't miss opportunities to charge separately when documentation supports:

A. Separate specimens. "If the pathology report documents separately identified and diagnosed specimens you should code each separately," Padget says.

Example: If the pathologist diagnoses nasal turbinate and a nasal polyp, code 88304 x 2.

B. Multiple units: You can also code separately for multiple units, such as two separately identified mucosal biopsies.

Example: "If the surgeon identifies and the pathologist diagnoses two distinct nasal mucosal biopsies, you should report 88305 x 2," Padget says. C. Separate sides: A pathologist might receive sinus contents in separate containers marked "left" and "right." That's when you should code 88305 x 2 for two, distinct sinus-content specimens.

Warning: "If the referring physician fails to distinguish two or more tissue samples -- like right and left nasal polyps thrown into one container without any way to tell which is which -- you're stuck with having to bundle all the material under one charge code," cautions Padget.