Pathology/Lab Coding Alert

Grab separate biopsy, aspirate, and clot pay.

Bone marrow cases can have lots of complicated parts, some of which you can -- and some of which you can't -- separately bill.

That's why you need to track our experts through the following case study to learn how to seize the opportunities, avoid the pitfalls, and get home by six.

Read the Path Report

Study the following abbreviated pathology report and see if you can tease out the procedures that you should bill for the case.

Patient: 72-year-old female Medicare beneficiary, outpatient procedure

Specimen: Bone marrow biopsy and aspirate, peripheral blood smear

Gross description: The specimen is labeled as right posterior iliac crest bone marrow biopsy and consists of a core of brown-tan bone measuring 2.0 x 0.2 cm and abundant red fibrinous clots measuring 1.0 cm in aggregate. The bone is decalcified and totally submitted labeled

A1. The clots are submitted labeled A2. Interpret iron, kappa and lambda stains for A1 and A2.

B1: Three bone marrow aspiration smears labeled right iliac crest for direct smear exam, Wright, Giemsa and iron stains.

C1: Bone marrow aspirate particle clot. Iron, kappa and lambda stains.

Final Diagnosis: Bone marrow biopsy - hypercellular bone marrow. Bone marrow aspiration - possible erythroid hyperplasia. Peripheral smear - rouleaux.

Once you've tried to code the case yourself, you can use the following three tips to check your hematopathology coding know-how.

Tip 1: Biopsy and Aspirate Stand Alone

Your pathologist's examination of a bone marrow biopsy and a bone marrow aspiration represent two distinct specimens that you should bill individually.

"Bone marrow biopsy and aspiration can provide different diagnostic information for certain leukemia evaluations, so taking both specimens from the same patient on the same day isn't unusual," explains says R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.

Report this:

• 88305 -- Level IV - Surgical pathology, gross and microscopic examination, Bone marrow, biopsy
• 85097 -- Bone marrow, smear interpretation
• 88305 -- ... Cell block, any source.

You should report only one unit of 88305 for the two blocks (A1 and A2) prepared from the biopsy specimen. The bone core and fibrinous clots represent a single biopsy specimen.

On the other hand: When the pathologist evaluates a particle clot (cell block) processed from the bone marrow aspiration specimen, the cell block represents an additional specimen that you should bill separately.

Capture decalcification: Notice that the gross description states that the bone is decalcified. That means you should also report +88311 (Decalcification procedure [List separately in addition to code for surgical pathology examination]).

Red-light peripheral blood smear: You can't separately bill for the peripheral blood smear in this case. See "85060: Limit Peripheral Smear to Medicare Inpatients" on this page to learn why.

Tip 2: Some Stains Aren't so 'Special'

Although CPT® provides codes for special stains, not every stain is special.

"Coding convention dictates that you can't separately report the 'standard' stain for a specimen, because it's included in the specimen exam," says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

For almost all anatomic pathology tissue exams, the standard stain is hematoxylin and eosin (H&E), which you shouldn't report using a special stain code.

Bone marrow is different: The standard stain for bone marrow aspiration smears is Wright-Giemsa, so you shouldn't bill separately for these stains. That means you can't list a separate code for the Wright and Giemsa stains listed in the pathology report for the bone marrow aspiration.

"Coders can find this confusing, because you can separately bill for Wright or Giemsa as 'special stains' for other specimens," Slagle says.

For instance, you can separately bill a stomach biopsy Giemsa stain for H. pylori, which you would report as 88312 (Special stain including interpretation and report; Group I for microorganisms [e.g., acid fast, methenamine silver]).

Tip 3: Beware Stain Units of Service

Based on tip 2, you can look back at the pathology report and decide which stains warrant a special stain code, but do you know how many units to report?

Per stain: You can always report each distinct stain. But after you've identified the distinct stains, you have to decide whether to report the stain per specimen, per block, or per smear.

"The units of service vary depending on whether you're coding a special stain such as 88312 or an immunohistochemistry [IHC] stain using 88342 [Immunohistochemistry (including tissue immunoperoxidase), each antibody]," Slagle says.

Follow CPT® guidance: Text notes preceding 88312 and 88313 (...Group II, all other (e.g., iron, trichrome), except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry) provide the following instruction:

"Report one unit of 88312, 88313 for each special stain on each surgical pathology block, cytologic specimen, or hematologic smear."

CMS concurs with this usage, based on instruction in the Correct Coding Initiative (CCI) Policy Manual: "If it is medically reasonable and necessary to perform the same stain on more than ... one block of tissue from the same specimen, additional units of service may be reported for the additional ... block(s)."

That means you can bill the iron stains for the case as 88313x6 based on the following breakdown:

• bone marrow biopsy block A1 iron stain - one unit 88313
• bone marrow biopsy block A2 iron stain - one unit 88313
• three direct smears bone marrow aspiration B1 iron stains - three units 88313
• bone marrow aspiration cell block specimen C1 iron stain - one unit 88313.

IHC is different: Unlike 88312-88313, CPT®doesn't instruct coders to report 88342 per block. Nor does CMS sanction that practice. In fact, the CCI Policy Manual states, "If a single immunohistochemical stain (procedure) for one or more antibodies is performed on multiple blocks from a surgical specimen, multiple slides from a cytologic specimen, or multiple slides from a hematologic specimen, only one unit of service may be reported for each separate specimen."

For the two IHC stains in this example -- kappa and lambda -- you can report 88342x4 based on the following breakdown:

• bone marrow biopsy specimen, blocks A1 and A2 - 88342 for kappa and 88342 for lambda
• bone marrow aspiration cell block specimen C1 - 88342 for kappa and 88342 for lambda.

Caution: Labs might examine kappa and lambda by different lab methods such as in situ hybridization (ISH) or flow cytometry, and in those cases, you would report codes other than 88342. You should not report different methods for the same markers from the same specimen.