Pathology/Lab Coding Alert

Lost pay isn’t the only potential penalty.

Coders worry about “upcoding” and charging too much for services, but did you know that “downcoding” can be just as bad? In fact, undercoding for lab or pathology services can cause significant financial and professional woes.

Read on to learn why precise documentation matters, as well as ways to avoid accidental undercoding.

Avoid Downcoding This Case

Look at the following case to understand two ways you could easily undercode the services.

Case: Based on a prior stomach biopsy positive for adenocarcinoma, the surgeon submits a partial gastrectomy specimen and separately submits seven lymph nodes from the gastro-omental region for suspected metastasis. The pathologist finds no residual tumor in the stomach tissue, but diagnoses chronic atrophic gastritis with glandular hyperplasia. The pathologist also reports that the lymph nodes are clear with no metastatic disease.

The two code choices for the pathology exam of a partial gastrectomy are as follows:

• 88307 (Level V — Surgical pathology, gross and microscopic examination, … stomach — subtotal/total resection, other than for tumor …)
• 88309 (Level VI — Surgical pathology, gross and microscopic examination, … stomach — subtotal/total resection for tumor …)

Wrong: The first common downcoding error in this scenario would be to code the pathologist’s work as 88307 based on the final diagnosis of gastritis with no neoplastic findings.

Here’s why: “Because the surgeon removed part of the stomach due to a prior cancerous biopsy, and the pathologist examined the specimen looking for tumor, including a margin evaluation, the service earns 88309,” explains R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Arkansas.

Wrong again: Even if you got the correct 88309 code for the partial gastrectomy exam, if that’s the only code you report, you’re still undercoding.

Explanation: Although CPT^® definition and some coding guidance and convention bundles lymph nodes with certain surgical specimens as part of the pathologic exam, stomach is not one of those specimens. Rather than bundling the lymph node exam into the 88309 resection exam, you should bill an additional unit of 88307 for a gastro-omental lymph node resection (88307 … Lymph nodes, regional resection …).

Reporting a lower service code or bundling services that should be separate procedures are two ways you might undercode this case, either of which could cost you appropriate pay for .

Know That Undercoding Can Be Fraudulent

The scary f-word in healthcare is fraud, which the Centers for Medicare & Medicaid Services (CMS) defines as “an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.”

This case: Ways you might fraudulently bill a gastrectomy case would be billing an additional lymph node resection if the stomach specimen simply includes one attached incidental lymph node. Or another way would be billing the case as 88307 because your insurer readily accepts those claims, but flags 88309 stomach cases for review, which you want to avoid.

Prioritize accuracy: As a coder, you know that your efforts do a lot to dictate a patient’s narrative of health and illness; you provide an official record of their condition. Therefore, making sure your code choices reflect the patient’s specific situation is crucial for myriad reasons.

“It’s important to make sure that we code accurately. Downcoding, undercoding, trying to capture it just for money is wrong. You may find yourself in a really compromised situation,” says Terry Fletcher, BS, CPC, CCC, CEMC, SCP-CA, ACS-CA, CCS-P, CCS, CMSCS, CMCS, CMC, QMGC, QMCRC, owner of Terry Fletcher Consulting Inc. and consultant, auditor, educator, author, and podcaster at Code Cast, in Laguna Niguel, California.

Of course, coders who intentionally undercode may think they’re doing something helpful, either by avoiding expense for a patient or a payer or trying to avoid a mistake made in a prior authorization. “Coding lower to avoid problems is an old school mentality to avoid problems, but CMS has been clear that any inaccurate coding, high or low, is inappropriate,” explains Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/ auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

Additionally, “the medical records are a history of what was addressed and treated during the visit. If the documentation is too vague to code, then most likely there are significant gaps in the documentation that need to be addressed to have an accurate record of what occurred,” Johnson continues.

Avoid Undercoding By Following These Best Practices

Undercoding can be accidental, but it still carries the potential for big consequences. Here are some pointers on how you can strive for accuracy every time.

Stay up to date: Coders have a responsibility to keep informed about the latest industry changes, including updates to guidelines and regulations. The more you know, the easier it is to assign the correct codes.

Thoroughly review documentation: Carefully read the documentation, including medical notes, lab results, and pathology reports. This will help ensure you capture all the services provided.

Be specific: The more specific the code, the better it reflects the service(s) provided.

Know payer policies: Different payers have different requirements, so familiarize yourself with these policies and contact the payer directly whenever you have a question about how to properly submit a claim.

Communicate and educate: Always keep an open line of communication with your healthcare providers to clarify any questions or concerns about proper coding. The goal is to accurately reflect the services provided. As a coder, you’re the expert and may have to occasionally review guidelines and regulations with the providers to help them improve their documentation.