Pathology/Lab Coding Alert

Specimens, blocks, smears or stains - just what is the unit of service for pathology procedures ? If you answered "all of the above," you would be correct - but not all of the time. Our experts will show you the proper units for a myriad of different pathology services.
 
"If you don't get the unit of service right, you could cost your practice in uncollected revenues," says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

Code per Smear Method for Cytopathology

Non-gynecological cytopathology codes 88104-88108 may say "smears" in the definitions, but that doesn't mean you'll report only one procedure code for all smears from a single source. "If the lab uses different methods to process and evaluate smears from a single source, such as direct smears, cytospins, and cell block, you should separately report each method," Slagle says.
 
For example, if the lab prepares and interprets a direct smear from a bronchial washing and also spins the remaining sample to concentrate cells for smear preparation and interpretation, you should report two separate cytopathology procedures. The codes are 88104 (Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation) and 88108 (Cytopathology, concentration technique, smears and interpretation [e.g., Saccomanno technique])
 
You cannot bill both codes to Medicare without a modifier because of a National Correct Coding Initiative (NCCI) edit. When you perform both 88108 and 88104 on the same day due to medical necessity, append modifier    -59 (Distinct procedural service) to indicate that you performed two separate cytology procedures. "The pathology report must document that you performed two separate services, stating, for example, that you performed a 'direct smear' and a 'cytospin,' " Slagle says. 

Report Each Specimen for Surgical Service

You should report surgical pathology codes based on the specimen, regardless of how many containers, blocks or slides the pathologist examines. Codes 88300-88309 represent ascending work levels (Levels I-VI) defined as "surgical pathology, gross and microscopic examination" (except 88300, which is gross examination only). A list of specimens follows each code, and you should assign the code based on the type of specimen.
 
For example, if the surgeon submits a left breast in one container and associated left axillary lymph nodes in another, you should report 88309 (Level VI - surgical pathology, gross and microscopic examination, breast, mastectomy - with regional lymph nodes). "You should code based on the defined specimen, not based on the number of containers," says R.M. Stainton Jr., MD, president of Doctor's Anatomic Pathology, an independent pathology laboratory in Jonesboro, Ark.
 
The number of tissue blocks and slides doesn't affect code selection either. For instance, if the pathologist examines a sentinel lymph node, you should report 88307 (Level V - surgical pathology, gross and microscopic examination, sentinel lymph node). "It doesn't matter if the pathologist prepares five paraffin blocks and stains five serial sections per block with hematoxylin and eosin (H&E) for a total of 25 slides; you should still report one unit of 88307 to represent the sentinel lymph node exam," Stainton says.

'Service' Is the Unit for Ancillary Surgical Pathology

Coding surgical pathology per specimen doesn't mean that you'll never report other codes for a given specimen. In fact, CPT lists ancillary surgical pathology procedures that you should report per service. "But the specimen is still the basis of the service - you should report each service once per specimen, not once per block or slide," Stainton says.
 
For example, if the pathologist examines a bone marrow biopsy and performs a decalcification and iron stain, you should report three codes. According to Stainton, you should code the specimen exam as 88305 (Level IV - surgical pathology, gross and microscopic examination, bone marrow, biopsy), the decalcification as +88311 (Decalcification procedure [list separately in addition to code for surgical pathology examination]) and the iron stain as +88313 (Special stains [list separately in addition to code for surgical pathology examination]; group II, all other [e.g., iron, trichrome], except immunocytochemistry and immunoperoxidase stains, each). The number of blocks and slides does not affect this coding. 
 
But if the pathologist examines a single specimen with multiple different stains, not just multiple slides with a single stain, you should report multiple units of a stain code. Remember the rule - code per service, per specimen.
 
If the pathologist processed two blocks from a lung biopsy and examined two slides with an acid fast bacillus stain from one block, and three slides with a Grocott's methenamine silver (GMS) stain from the other block, you should report two units of +88312 (Special stains [list separately in addition to code for surgical pathology examination]; group I for microorganisms [e.g. Gridley, acid fast, methenamine silver], each). "The code definition says 'each,' indicating that you should report the code for each different stain used on a single specimen," Stainton says.

Report Aspirations per Service, per Site

The pathologist may perform a multistep procedure to complete a fine needle aspiration. For a given lesion or site, you should report each step separately. If the pathologist draws the aspirate into the needle, checks the specimen to ensure the presence of adequate cells for examination, and then performs the examination and interpretation, you should report three separate codes. The codes are 10021 (Fine needle aspiration; without imaging guidance) for withdrawing the aspirate, 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]) for the adequacy check, and 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report) for the interpretation.
 
But watch out - you shouldn't report these codes more than once for the same source. "Obtaining an adequate aspiration specimen may require multiple passes from the same lesion, but you should report 10021 and 88173 only once per lesion, not once per pass," Slagle says.
 
You can report multiple units of 88172 for the same lesion in some circumstances, according to Slagle. If the surgeon withdraws the aspirate and requests that the pathologist determine specimen adequacy for two different passes submitted at two different times, you can report the pathologist's service as 88172 x 2.