Pathology/Lab Coding Alert

Coding for pathologic evaluation of tissue from complex surgical procedures, such as a Whipple resection, involves appropriately reporting each specimen and service provided. However, coders must be cautious to avoid unbundling.
 
"Complex surgical specimens are especially susceptible to either underreporting or unbundling," says R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services, an independent pathology laboratory in Jonesboro, Ark. When the surgeon removes multiple organs or portions of organs, pathology Coder may struggle to identify accurately what constitutes the individual specimen, which is the unit of service for surgical pathology.

Correct Coding for Surgical Pathology

 
The Whipple-type procedure involves the excision of various organs (or portions of organs) for the treatment of pancreatic cancer. The tissue removed may vary based on the surgeon's evaluation of the individual case. "In addition to the pancreas and duodenum, tissue received from a Whipple resection might include the gallbladder, the spleen, a portion of the stomach, the common bile duct, lymph nodes and other tissues," Stainton says.
 
CPT defines the specimen (the unit of service for codes 88300-88309) as "tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis." Coders are also told that "Two or more such specimens from the same patient are each appropriately assigned an individual code reflective of its proper level of service." CPT further states that "Any unlisted specimen should be assigned to the code which most closely reflects the physician work involved when compared to other specimens assigned to that code."
 
Incorrectly applying these surgical pathology coding principles can cause either unbundling, which could constitute fraud, or undercoding, which could result in sacrificing income for services rendered. "In the case of Whipple resections, some pathologists believe that the pathologic evaluation should be reported as a single, unlisted specimen to avoid the appearance of unbundling," Stainton says.
 
Others believe that reporting a Whipple evaluation as one service would amount to undercoding because it involves evaluation of one or more specimens listed in the CPT surgical pathology section.

Harvard Vignettes

 
The debate stems in part from vignettes developed for the National Study of Resource-Based Relative Value Scale for Pathologist's Services (Hsiao, W.C., Ph.D., et al., Harvard School of Public Health, 1991) that were used to formulate the current surgical pathology coding scheme introduced in CPT 1992. One vignette listed "gross and microscopic examination of a Whipples resection (gastriopancreoduodenectomy) for a mass in the head of the pancreas" as an 88309 (level VI - surgical pathology, gross and microscopic evaluation). Based on this narrative, some pathologists consider a Whipple resection to be an unlisted specimen, reported as 88309.
 
"However, reporting pathologic evaluation of a Whipple resection as an unlisted specimen, when in fact the resection includes a varying number of listed specimens, flies in the face of CPT coding principles for surgical pathology," says Dennis Padget, CPA, FHFMA, president of Padget & Associates, a Kentucky-based pathology and laboratory billing and compliance consulting firm serving more than 150 clients in 25 states.
 
Correct coding involves accurately describing the service rendered based on the listed specimens, as much as possible. "Neither breaking a listed specimen into component parts and reporting them separately nor bundling listed specimens together into a new 'unlisted' specimen reflects correct coding for surgical pathology," Padget says.
 
Padget rebuts the view that the old Harvard study is relevant to contemporary coding for unlisted specimens. "The Harvard team developed a physician work-based crosswalk among medical procedures for all specialties," he recalls. "Vignettes, including several for surgical pathology procedures, were constructed for these purposes. However, a different project team including representatives of the various medical specialties, the AMA itself, and HCFA (now CMS) took over at that point. That team developed a coding and medical procedure definition framework through which the Harvard RVUs would be converted to payment rates.
 
"The procedure definition/coding scheme team accepted some Harvard vignettes verbatim, but others were modified or summarily rejected. For example, with rare exception, terminology appropriate for describing medical services from the perspective of a surgeon (e.g., cystoprostatectomy, gastroduodenectomy, pneumonectomy, Whipple) was ultimately deemed inappropriate for use in describing surgical pathology specimens," Padget says. Pathology service coders were instructed beginning with CPT 1992 (Winter 1991 CPT Assistant) to consult the 170 or so specific tissues listed in the formal text when making coding decisions, and to consider only those classifications when making decisions regarding unlisted specimens.
 
"There is nothing I have ever come across from the AMA or in Medicare program instructions that suggests in any way that the Harvard vignettes are compelling or influential as regards post-1991 coding decisions. Third-party payer auditors correctly cite only those instructions and tissue types enumerated in the CPT text, or classification of unlisted tissues extrapolating only from those expressly named in the text, when judging the efficacy of contemporary pathologist claims," Padget says.

Clinical Example

 
A patient presented with jaundice and abdominal tenderness. History and physical examination revealed palpable gallbladder, with no history of gallstones or alcohol use indicating pancreatitis. The physician ordered serum bilirubin (82247), which returned elevated; fecal occult blood test (82270), which returned hemoccult positive; and an endoscopic retrograde cholangiopancreatography (ERCP). The ERCP revealed massive dilation of the gallbladder and common bile duct to the level of the ampulla of Vater and head of the pancreas.
 
An exploratory laparotomy confirmed the distended gallbladder and obstruction and dilation of the common bile duct, as well as elucidating an enlarged pancreas with a 5-cm mass in the head. Based on these findings, the surgeon proceeded with a cholecystectomy, along with biopsy of the common bile duct, celiac lymphadenectomy and a Tru-Cut biopsy of the head of the pancreas.
 
The pathologist consulted on frozen sections from two tissue blocks from the pancreatic biopsy. This service is reported as 88331 (pathology consultation during surgery; first tissue block, with frozen section[s], single specimen) and 88332 (... each additional tissue block with frozen section[s]). The frozen sections were diagnosed as adenocarcinoma, 157.0.
 
Pathologic evaluation of the specimens removed in the exploratory surgery includes:
 

Cholecystectomy -- 88304 (level III - surgical pathology, gross and microscopic examination; gallbladder). The diagnosis, chronic cholecystitis (575.11), no gallstones;
 

Bile duct biopsy -- 88305 (level IV - surgical pathology, gross and microscopic examination). This is an unlisted specimen, so the code is assigned on the basis of the level of work involved, which is similar to several other listed biopsy specimens in 88305;
 

Celiac lymph nodes -- 88307 (level V - surgical pathology, gross and microscopic examination; lymph nodes, regional resection); and
 

Pancreas biopsy -- 88307 (level V - surgical pathology, gross and microscopic examination; pancreas, biopsy). The diagnosis is adenocarcinoma, 157.0.
 
Based on clinical findings and biopsy reports pointing to a resectable mass in the head of the pancreas, the patient underwent a Whipple procedure. The surgeon carried out a pylorus-preserving Whipple, removing 50 percent of the pancreas, near total duodenum, the spleen and five peripancreatic lymph nodes.
 
Pathologic evaluation of the tissue removed in the Whipple procedure includes the following:
 

Pancreas (including attached peripancreatic lymph nodes, which are bundled) -- 88309 (level VI - surgical pathology, gross and microscopic examination; pancreas, total/subtotal resection);
 

Duodenum -- 88307 (... small intestine, resec-tion, other than for tumor); and
 

Spleen -- 88305 (... spleen).

Coding Pathologic Evaluation for Whipple Tissues

 
"The tissue received from a Whipple resection is not the same for every procedure, so the coding varies depending on what specimens are submitted for pathologic evaluation," says Shirley Myers, senior pathology production unit manager in charge of coding and billing for Whipple procedures at Johns Hopkins University in Baltimore. "At our institution the surgeons and pathologists are careful to identify clearly the separate tissues requiring examination and diagnosis."
 
Myers explains that the organs primarily removed in a Whipple resection are the pancreas and the duodenum, which are listed specimens in CPT surgical pathology and should be coded accordingly.
  
As in the preceding case study, the evaluation of the pancreas is reported as 88309 and the duodenum as 88307. Lymph nodes associated with the removed organ, such as the peripancreatic lymph nodes, are bundled and should not be reported separately. "On the other hand, if a distant regional resection such as the periportal lymph nodes is also conducted, the pathologic evaluation would be reported as 88307 (... lymph nodes, regional resection)," Stainton says.
 
The Whipple resection may involve other specimens that are separately reportable. In the case study, the gallbladder was removed prior to the Whipple resection. According to Myers, the gallbladder is often removed concurrent with the pancreas and duodenum and is separately evaluated and reported using 88304 (... gallbladder). In a classic Whipple procedure, a portion of the stomach is removed, and both the pathologic examination and diagnosis are reported using 88307 (... stomach - subtotal/total resection, other than for tumor). "Sometimes the spleen is also removed and evaluated for involvement in metastases, which is reported as 88305 (... spleen),"  Myers says.
 
"Although not actually part of the Whipple resection, it is not unusual to receive a liver biopsy for the same patient on the same day," Myers reports. The liver biopsy is a separate service, reported as 88307 (... liver, biopsy - needle/wedge). During the Whipple procedure, the pathologist is often asked to evaluate the distal pancreas margin using frozen sections, Myers says. The frozen sections are reported as 88331 for the first block, and 88332 for each additional block.