Pathology/Lab Coding Alert

When the pathology report uses different language than the code books, you need a translator. Terms like tumor" " "benign " "polyp" and "primary" define the procedure and diagnosis codes for colon specimens but the pathology reports may not contain these exact words.

"We assign the procedure and diagnosis codes for colon specimens based on the pathology report " says Elizabeth Sheppard HT (ASCP) manager of Anatomic Pathology at Wake Forest University Baptist Medical Center in Winston Salem N.C. You must be familiar with the terminology in the medical record whether it's specific histologic nomenclature or morphology of neoplasm codes. You must also be able to translate the terminology into the correct CPT and ICD-9 code for labs that assign diagnosis codes based on the pathologic findings.

"Assigning procedure codes for the colon is straightforward but we don't assign the ICD-9 codes in our practice " says Stephen Yurco III MD partner and pathologist at Clinical Pathology Associates in Austin Texas. "Because the final colon diagnosis is not pertinent to CPT coding except to know whether a partial resection is for a tumor we leave the ICD-9 coding to the clinician who ordered the test."

Specimen and Diagnosis Determine Procedure Code

"Pathologists report examination of colon tissue using one of four surgical pathology codes " Yurco says. Bill the colon and skin tissue from a colostomy with 88304 (Level III Surgical pathology gross and microscopic examination colon colostomy stoma). For a colon biopsy or polyp report 88305 (Level IV Surgical pathology gross and microscopic examination colon biopsy; or polyp colorectal). "Regardless of the diagnosis pathologists bill 88305 for a colon polyp or biopsy " Yurco says.

"Sometimes surgeons will excise multiple polyps and submit them for diagnosis " Yurco says. "If they are submitted for individual examination based on a surgical note or physical mark to distinguish the specimens it is appropriate to report multiple units of 88305. But be careful to individually list each specimen and the pathologic findings in the pathology report to document multiple specimens."

Report a partial colon resection using one of two different codes depending on whether or not a neoplasm is involved: 88307 (Level V Surgical pathology gross and microscopic examination colon segmental resection other than for tumor) or 88309 (Level VI Surgical pathology gross and microscopic examination colon segmental resection for tumor). Also use 88309 ( colon total resection) to report a total resection regardless of the diagnosis.

For the partial resection you should know something about the diagnosis of neoplasm. "If the patient has a confirmed diagnosis of colon tumor based on a previous biopsy for example report 88309 whether or not the current resection is neoplastic " Yurco says. "Otherwise report 88307 or 88309 based on whether or not the partial resection specimen is a neoplasm.

"Knowledge of terminology helps to determine if the specimen fits the 'tumor' distinction or not " Yurco says. "Otherwise if the ICD-9 coding is left to the clinician you don't need to know much detail about the diagnosis. I strongly recommend this approach since the diagnosis has little impact on payment for the pathologist's services."

Know Colon Morphology Terms

Coders who assign the CPT or ICD-9 codes will benefit from a basic understanding of morphological terminology especially as it relates to neoplasm.

Morphological descriptions of non-neoplastic colon polyps include:
 

Hyperplastic Frequently found in the colon these polyps seldom lead to cancer. Report the polyp examination as 88305 a partial resection as 88307. Lacking a more specific code the correct ICD-9 code for this condition is 569.9 (Unspecified disorder of intestine).
 

Inflammatory or pseudopolyps These are often found in patients with inflammatory bowel disease or ulcerative colitis. The pathology exam is 88305 for a polyp 88307 for segmental resection. The ICD-9 code is 556.4 (Pseudopolyposis of colon).

Hamartomatous Also called Peutz-Jeghers polyps these should be reported as 759.6 (Other and unspecified congenital anomalies; other hamartoses not elsewhere classified).

Pathology reports often use phrases describing colon tissue morphology that indicate a specific behavior. Understanding the relationship between a particular morphology and its usual behavior helps coders to know whether the specimen is benign or malignant. Common morphological descriptions of neoplastic colon include:

Adenoma Although colorectal cancers can arise from this type of tissue or polyp the behavior of most adenomatous polyps is benign and the diagnosis code is 211.3 (Benign neoplasm of colon). Pathologists may further define these benign specimens as "tubular adenoma" or "tubulovillous adenoma." A villous adenoma is considered of "uncertain behavior" and should be coded as 235.2 (Neoplasm of uncertain behavior of stomach intestines and rectum). The procedure code for examination of adenomatous colon is 88305 for a polyp or biopsy and 88309 for a segmental resection.
 

Adenocarcinoma When an adenoma becomes malignant it is called an adenocarcinoma. The pathologist may list histological subcategories of tubular or villous adenocarcinoma. Because these are malignant the diagnosis code depends on the specific site and metastatic state of the cancer. Report the pathology exam as 88309 for resection 88305 for polyp or biopsy.

Use Neoplasm Table to Narrow Diagnosis

The Neoplasm Table in ICD-9 Volume 2 gives code numbers for neoplasms by anatomic site based on the behavior (malignant benign or uncertain) and metastatic state (primary secondary or in situ). Colon specimen diagnosis codes are listed under the heading "Intestine intestinal large." Non-neoplastic colon conditions are not in the table. You must glean pertinent information from the pathology report and use it to find the appropriate code in the table or elsewhere in ICD-9:
 

Tissue source: The pathology report should list the specific colon specimen site e.g. transverse sigmoid ascending descending. This information is essential for assigning the correct diagnosis for primary malignant colon neoplasms. Specific colon location does not affect code assignment for most other neoplastic behaviors.
 

Behavior of the neoplasm (its capacity to spread): The table primarily categorizes neoplasms as benign (211.3 for colon) or malignant (153.x or 197.5 or 230.x for colon). Uncertain behavior is another category reserved for specimens that cannot be clearly identified as malignant or benign following testing (235.2 for colon). The "unspecified" category commonly characterizes neoplasms that have not yet been tested to determine their behavior (239.0 for colon). "Unfortunately for coders the pathology report may not use these terms at all but instead may list other morphology terminology or codes " Sheppard says (see Translating the "Morphology of Neoplasms" Table in article two).

Metastatic state of malignancies: The pathology report should indicate whether the tumor is "primary " meaning the tumor originated in the colon (153.x depending on the specific location); "secondary " meaning the cancer metastasized from another location (197.5); or "in situ " meaning the tumor has a nonspreading behavior (230.3). For example the report might state "adenocar-cinoma" for a primary malignancy or "adenocarcinoma metastatic" if the colon is the secondary site or "adenocarcinoma in situ." Some pathology reports use the terminology "metastatic from" the primary site or "metastatic to" the secondary site.

It is sometimes difficult to determine the primary site of a cancer because it has already spread to neighboring tissue. According to ICD-9 direction use 153.8 for a "malignant neoplasm of contiguous or overlapping sites of colon whose point of origin cannot be determined."

"You should never assign the diagnosis code directly from the alphabetic index [ICD-9 Volume 2] and that includes the neoplasm table " Sheppard cautions. "You must always turn to the tabular list [ICD-9 Volume 1] because it provides other coding direction." For example 153.3 (Malignant neoplasm of the sigmoid colon) specifies that it "excludes rectosigmoid junction " which is reported as 154.0.