Pathology/Lab Coding Alert

Make sure your pathologist has the tools.

Your coding skills might be top notch, but your reporting can only be as good as the information the pathologist gives you.

With new CPT® 2014 codes firmly under your belt and ICD-10 implementation bearing down on you, now is a great time to focus on documentation that can help you earn all the pay you deserve and avoid audit problems — or even fraud charges.

ICD-10 and CPT® Require Details

Whether assigning a diagnosis or procedure code, you’ll need specific information from the pathology report to choose the right code.

Under ICD-10, physicians will need to beef up their documentation, according to Arlene Maxim, RN founder of A.D. Maxim Consulting, A.D. Maxim Seminars, and The National Coding Center, in Troy, Mich. “Documentation will make or break this process,” says Maxim, because ICD-10 will require a higher degree of specificity.

Reporting pathology procedures also requires detailed information. For instance, to choose the correct procedure code, you’ll need to know if a breast specimen is a biopsy or a lumpectomy, or whether or not a colon resection is for tumor.

Documentation is key: Clinical documentation is the foundation of every health record, according to Dorothy D. Steed, CPC-H, CHCC, CPUM, CPUR, CPHM, ACS-OP, CCS-P, RCC, CPMA, RMC, CEMC, CPC-I, CFPC, PCS, FCS, CPAR, AHIMA Approved ICD-10 Trainer, an independent healthcare consultant and educator in Atlanta, Ga.

Clinicians may collect documentation only once, but others will use it many times, said Steed during the recent audioconference “Clinical Documentation Improvement” sponsored by The Coding Institute affiliate AudioEducator.com. The “coder needs high quality documentation to ensure coding quality and accuracy,” she said.

Check These Documentation Criteria

Here are seven criteria for quality documentation. Make sure your pathologists’ record keeping will pass muster with these expert tips.

1. Legibility: Documentation should be readable and easily deciphered, but a lot of handwritten documentation isn’t, Steed cautioned. Complete and legible entries provide protection for providers. But illegible entries in a medical record may cause:

• Misunderstanding of a patient’s condition
• Jeopardized reimbursement
• Denied payment
• Loss of legal appeals.

Remember: Legibility includes being able to read the name and title of the physician completing the documentation.

2. Reliability: The documentation should support the rationale for the diagnosis and medical necessity for the procedure. If it doesn’t, you should question the reliability of the note and ask the pathologist for clarification.

Most denials and down coding occur when at least part of the documentation doesn’t support the codes you report.

3. Precision: Clinical documentation must be exact, and strictly defined. Make sure your pathologist uses terms precisely, such as using “biopsy” to refer to specimens that do not involve margin exam.

4. Completeness: Good documentation fully addresses all necessary items, including complete patient information, procedure description, diagnosis statement, and physician identification.

5. Consistency: Documentation shouldn’t be contradictory. If there are conflicting statements in the record, such as a difference between the pathologist’s and surgeon’s specimen identification, make sure they are addressed.

6. Clarity: Documentation should be unambiguous. Vague pathology reports using phrases such as “stain non-contributory” won’t support the services your pathologist provides.

7.Timeliness: Documentation must be up to date to help ensure optimal patient treatment.

Example: The surgeon submits a breast “lesion excision,” upper inner quadrant, from a patient with a prior biopsy diagnosis of ductal carcinoma in situ (DCIS). The pathologist examines the specimen using hematoxylin and eosin (H&E) stained slides and diagnoses infiltrating ductal carcinoma.

Solution: As documented, you should code the case as 88305 (Level IV - surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins) for the pathologist’s specimen exam. Although the surgeon submitted a lesion excision, the pathologist did not document a margin exam, so you cannot accurately code the case as 88307 (Level V - surgical pathology, gross and microscopic examination, breast, excision of lesion, requiring microscopic evaluation of surgical margins). If the pathologist had added “margins clear” to the diagnosis statement, this case would earn 88307, which pays $217.80 more than 88305 (Medicare Physician Fee Schedule national amount, conversion factor 35.8228).

For the diagnosis, you should report 174.2 (Malignant neoplasm of upper-inner quadrant of female breast) because that is the final diagnosis. Don’t revert to the ordering diagnosis of DCIS (233.0, Carcinoma in situ of breast).