Pathology/Lab Coding Alert

Don't bill separately for 88184-88189 cell review

If you're billing separately for a cytology smear exam with flow cytometry--watch out. You could be unbundling.
 
Regardless of the specimen--peripheral blood, aspirates, tissue or cytology specimens--the lab prepares a cellular suspension before performing flow-cytometry analysis. Can you bill for the original specimen exam, a slide evaluation from the cell preparation, and the flow cytometry? If you do, you could be double-dipping and risking fraud charges.

Bill for Separate Specimen Exam

Pathologists often integrate both a specimen exam and flow cytometry for the evaluation of hematolymphoid cancers. "You can code separately for the tissue or aspiration exam along with flow cytometry codes for the same specimen," says William Dettwyler, MT-AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore.

Example: The pathologist extracts a bone-marrow aspirate, examines direct smears from the aspiration, and processes and examines a cell block. Based on findings indicating myeloid leukemia, the lab concentrates the remaining aspirate and runs an immunophenotyping flow-cytometry panel on the cell suspension, including markers CD45, CD34, CD15, CD14, CD13, CD33, CD7 and CD19.

You should individually code the bone marrow aspiration and exam, the cell block, and the flow cytometry as follows:

• CPT 38220 --Bone marrow; aspiration only

• 85097--Bone marrow, smear interpretation

• 88305--Level IV--Surgical pathology, gross and microscopic examination, cell block, any source

• 88184--Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker

• +88185--...each additional marker (list separately in addition to code for first marker) (Report seven units of 88185, one for each marker beyond the first.)

• 88187--Flow cytometry, interpretation; 2 to 8 markers.

Flow Cytometry Includes Morphologic Cellular Evaluation

In the prior example, the lab concentrates the aspirated cells, enhancing the cell suspension for flow cytometry. But even if the pathologist examines smears or thin-layer preparation slides as part of the flow cytometry service, you should not separately report cytology code 88108 (Cytopathology, concentration technique, smears and interpretation [e.g., Saccomanno technique]) or 88112 (Cytopathology, selective cellular enhancement technique with interpretation [e.g., liquid-based slide preparation method], except cervical or vaginal). "The flow cytometry service includes a cytology smear interpretation," Dettwyler says.

Bottom line: Don't use two different cytology procedure codes for the same specimen. "Report the most extensive cytopathology service that the pathologist performs on a given specimen to reach a diagnosis," Dettwyler says. 

NCCI Bundles Cytopathology Codes

The National Correct Coding Initiative edits confirm that you should select only one cytopathology method for a given specimen. NCCI bundles flow cytometry codes 88184-88189 with both cytology codes 88108 and 88112. Based on "standards of medical practice," CMS contends that the pathologist will routinely perform a morphologic cytology exam as part of a flow cytometry panel to interpret the findings and provide a diagnosis.

Go to the highest level: According to the NCCI policy manual, you should select the cytopathology code(s) "which describes, to the highest level of specificity, what services were rendered." Even if the pathologist performs two distinct cytology procedures for the same specimen, you should only report the most extensive service, Dettwyler says.

Use 59 With Separate Specimens

What if the pathologist interprets flow cytometry for one specimen and, on the same day, examines a separate non-gynecological cytopathology specimen? "You can override the NCCI edits for flow cytometry and 88108 or 88112 using modifier 59 (Distinct procedural service) if the cytology evaluations involve two distinct specimens," says Debbie Siena, HT(ASCP), QIHC, president of Tissue Techniques Pathology Laboratory in Dallas.

For instance: The pathologist prepares and examines a concentrated smear from a bronchoalveolar lavage (BAL) specimen and also evaluates a flow cytometry panel involving 12 markers from a lung biopsy specimen. "You can report 88188 for the flow cytometry interpretation and 88108 with modifier 59 for the BAL specimen," Siena says.