Pathology/Lab Coding Alert

Look for specific diagnostic statement.

If your lab encounters the following specimens and provides the following results, are you ready make the right call for procedure and diagnosis coding in this Crohn’s case study?

Read on to learn ways and means to capture the right codes and pay for your lab.

Study the Case and Findings

History: Male, 57 year-old patient presents with abdominal pain, four days vomiting and total constipation, history of Isoniazid medication for suspected abdominal tuberculosis. CT scan indicates possible intestinal obstruction.

Surgical report: During laparotomy, surgeon visualizes multiple strictures at terminal ileum and cecum, with obstructing stricture at hepatic flexure of colon. Surgeon performs right hemicolectomy including attached terminal ileum.

Pathology report: The lab processes the hemicolectomy in four blocks labeled as follows:

• A) Hepatic flexure
• B) Ascending colon
• C) Cecum
• D) Terminal ileum

Gross findings include areas of focal inflammatory process with dilated colon circumference, alternating with narrow portions of ascending colon containing normal tissue. Linear ulcers occur along bowel axis in parts of cecum, and terminal ileum, and hepatic flexure demonstrating a “cobblestone” appearance. Hepatic flexure demonstrates complete obstruction. The report notes, “Mesenteric fat wraps around 75 percent of the circumference at the terminal ileum.”

Microscopic findings include prominent, enlarged lymphatic follicles organized in fissures or ulcers extending from mucosa through muscularis mucosa and into the serosa, in some places. Marked inflammatory cell infiltrates involve all layers. Non-necrotizing granulomas are identified in the terminal ileum and cecum. Proliferation of muscularis mucosa, submucosa, and mucosa is identified as obstructing the hepatic flexure.

Based on prior patient treatment for tuberculosis, slides from multiple levels of granulomas sections from the terminal ileum and cecum are stained with Ziehl–Neelsen — findings negative for Mycobacterium tuberculosis.

Patient blood testing revealed normal red cell count of 4.62×1012 cells/L, elevated white cell count of 11.31 × 109 cells/L, and elevated C-reactive protein of 41.2 mg/L, indicating significant inflammatory process.

Diagnosis: Crohn’s disease with involvement of terminal ileum and blockage of hepatic flexure.

Capture Each Lab and Pathology Service

The pathologist examined a hemicolectomy specimen, which you should code as 88307 (Level V - Surgical pathology, gross and microscopic examination … Colon, segmental resection, other than for tumor …).

No matter how many blocks the lab processes for the specimen, or how many different specific colon locations the pathologist diagnoses, such as hepatic flexure, cecum, and ascending colon, you should code just one unit of 88307 for the single segmental colon resection specimen.

“Right colon resections typically include the terminal ileum, so you should not separately bill the small attached portion of small intestine that the pathologist evaluated as part of the hemicolectomy specimen in this case,” says R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services in Jonesboro, Ark

Proviso: If the surgeon separately submits a small intestine specimen that is more than a short segment of terminal ileum attached to the colon resection, you can separately bill the small intestine as an additional specimen using an appropriate code such as 88307 (… Small intestine, resection, other than for tumor …).

The pathologist uses hematoxylin and eosin (H&E) staining to identify most of the microscopic features indicative of Crohn’s disease, such as inflammatory cell infiltrates into all layers of the colon tissue. That’s the common morphology tissue stain, and you shouldn’t separately charge for H&E.

“On the other hand, if the pathologist identifies any special stains, such as for microorganisms, you should separately code those” says Peggy Slagle, CPC, coding and compliance manager for the department of pathology/microbiology at the University of Nebraska Medical Center in Omaha.

Capture this: The pathology report identifies Ziehl–Neelsen staining from blocks C and D, so you should report two units of 88312 (Special stain including interpretation and report; Group I for microorganisms [eg, acid fast, methenamine silver]).

CPT^® indicates that you should report special stain code 88312 once for each surgical pathology block, cytologic specimen, or hematologic smear.

Don’t miss lab tests: The treating physician in this case ordered lab testing to evaluate possible inflammatory processes at work in the patient. The clinical lab should report the appropriate tests ordered and performed, such as complete blood count (CBC) with differential to identify red and white cell counts, as well as C-reactive protein. Depending on the exact test the physician requests and the lab performs, you might report the following codes:

• 85025 (Blood count; complete [CBC), automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count)
• 86141 (C-reactive protein; high sensitivity [hsCRP]).

Zero in on Specific Diagnosis Code

The pathology report provides a diagnosis of “Crohn’s disease with involvement of terminal ileum and blockage of hepatic flexure.”

To find your way to the proper ICD-10 code, you need to start by focusing on the location of the inflammatory disease changes. Crohn’s disease involves chronic inflammation of almost any part of the gastrointestinal tract, though it most commonly affects the small intestine and colon.

Do not get overwhelmed with 28 code options for Crohn’s. You can nail the first four characters of the code with exact location of pathology. “You will be relying on your physician to be specific in describing which areas of the intestinal tract that are involved,” says Michael Weinstein, MD, former representative of the AMA’s CPT^® Advisory Panel.

The location choices are as follows:

• K50.0- (Crohn’s disease of small intestine…)
• K50.1- (…of large intestine…)
• K50.8- (… of both small and large intestine…)
• K50.9- (… unspecified…).

Once you’ve identified the location, you’ll need to know the symptoms to choose the most specific code. “Symptoms and anatomical position of symptoms are key,” says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president, Healthcare Resource Management, Inc. Spring Lake, NJ.

• 0 (…without complications)
• 1 (… with complications).

If your fifth digit is 0, you’ve arrived at the most specific code for the condition. But if the pathology report identifies complications, you’ll need to know more to assign the proper sixth digit from the following choices:

• 1 (…with rectal bleeding)
• 2 (…with intestinal obstruction)
• 3 (…with fistula)
• 4 (…with abscess)
• 8 (…with other complication)
• 9 (…with unspecified complications).

Bottom line: The most specific diagnosis code for this case is K50.812 (Crohn’s disease of both small and large intestine with intestinal obstruction).