Pathology/Lab Coding Alert

Watch for: The pathology exam must include a gross tissue description and evidence that the pathologist performed a microscopic exam (for 88302-88309). "If the lab accessions a labeled jar that is empty, you can't bill for the requested service," says Pamela Younes, MHS, HTL(ASCP), CPC, assistant professor at Baylor College of Medicine in Houston. Sometimes you'll see a gross tissue description but no findings from a microscopic exam.

For instance, if the pathology report includes a gross description of a very small specimen, but the tissue did not survive processing so that there are no results from a microscopic exam, you can only charge for the gross exam (88300).

Do this: The pathology report should document the work with terms such as "specimen processed and examined." Alternatively, the gross and microscopic description sections of the pathology report should demonstrate work by using descriptors such as "specimen measured ...," "sections exhibited ...," "one slide shows ...," or similar references to the pathologist's work.

2. Identify What You Have, Not What You Don't Have

If the pathology report documents the pathologist's gross and microscopic findings, you can charge for the service even if the findings don't provide a definitive diagnosis. On the other hand, if the pathologist simply states that the submitted specimen is "inadequate for evaluation," then you cannot charge for the service. 

Example: When the pathologist's findings don't match the submitted tissue description from the ordering physician, the pathology report should state what is present in the specimen block - not just what is absent. "If the physician thinks he's submitting a colon polyp but the pathologist finds and reports something else, such as colonic mucosa, you can still charge for the exam," says Stephen Yurco III, MD, partner and pathologist at Clinical Pathology Associates in Austin, Texas.

"But watch out how you word it," Yurco cautions. If the pathologist only reports that "no diagnostic epithelial polyp is present" but does not also state that the biopsy was normal, this could imply that no tissue was present. "The pathologist should also report the actual findings, such as 'sections demonstrate colonic mucosa' to document that adequate tissue was present to perform the biopsy evaluation," he says.

Best strategy: The pathologist should write, and the coder should find in the pathology report, a description of the specimen and the work involved in the exam. If the pathologist doesn't have enough tissue to make a definitive diagnosis, he should use terms such as "scant tissue present," or other phrases indicating actual findings. You can only bill the surgical pathology service when the report contains language that describes the findings.

Caution: If the pathologist states, "no tissue present" or "unsatisfactory (or insufficient or inadequate) specimen for evaluation," with no specific description of work or findings, you should not bill for a surgical pathology examination.

3. Select Appropriate Surgical Pathology Level

When you report a surgical pathology service, you select the proper code based on the listed specimens under each code. "When the pathologist describes something other than the expected tissue type, you have to select the code based on the actual work and the actual findings," Younes says.

Example: The pathologist receives a small specimen labeled "nasal polyp," and provides a gross description of the specimen, but the tissue does not survive processing. Due to the lack of tissue, the pathologist does not perform a microscopic exam, so you should not report the surgical pathology code for nasal polyps: 88304 (... polyps, inflammatory - nasal/sinusoidal). "You should report the actual service provided, which is an 88300 "gross only" exam," Younes says.

Warning: Don't ever report a code for unprocessed specimens, such as an empty container or a broken slide, because that constitutes fraud.