Pathology/Lab Coding Alert

Use these clinical examples to sharpen your skills

You're faced with a pathology report that provides no definitive diagnosis because of a lack of specimen quality or quantity. Depending on how the pathologist reports the findings, you could have a chargeable service - or not.

True or False: See if you agree with the coding in the following scenarios. Then check out our expert's advice about how proper documentation can help you accurately code for the work the pathologist performs.

Anatomic Pathology Report 1:

Specimen: Endometrium, biopsy

Diagnosis: Insufficient endometrium present for evaluation.

History: Post-menopausal on hormone replacement.

Gross description:

One specimen is received in formalin labeled with the patient's name and "endometrial biopsy." It consists of multiple pieces of red-brown mucoid material along with multiple pieces of red-brown tissue, measuring in aggregate 1 x 1 x 0.5 cm, entirely submitted in one cassette.

Microscopic Description:

Sections of the endometrial biopsy demonstrated a few detached fragments of benign endocervix admixed with blood and mucus. Insufficient endometrium is present for evaluation.

Code: CPT 88305

Our Expert's Advice:

The gross and microscopic descriptions document work and a description of the specimen, which should be a billable service. "But by stating, 'insufficient endometrium present for evaluation,' in the diagnosis line of the report, the pathologist gives the coder good reason to determine, 'no charge'," says Pamela Younes, MHS, HTL(ASCP), CPC, assistant professor at Baylor College of Medicine in Houston. If the pathologist instead reported a diagnosis that states the findings, such as "fragments of benign endocervix, blood and mucus present," you could clearly charge an 88305 (... endocervix, curettings/biopsy), according to Younes.

Anatomic Pathology Report 2:

Specimen A: Vocal cord, right true, biopsy

Diagnosis: No tissue present

Specimen B: Vocal cord, left true, biopsy

Diagnosis: Keratosis

History: Chronic hoarsness with vocal cord nodules.

Gross description:

There are two parts:

Part A: The specimen is labeled "right true cord biopsy." Received in formalin is a telfa pad without identifiable tissue elements. Nothing is submitted.

Part B: The specimen is labeled "left true cord biopsy." Received in formalin on a telfa pad is a single strip of gray-tan tissue measuring 3.0 x 0.5 x 0.5 mm. Submitted as B1.

Microscopic Description:

There is one slide with multiple levels of stratified squamous epithelium. There is atypia of the epithelium. There is maturation at the surface with focal paraderatosis The underlying stroma has mild myxoid change. No malignancy is seen.

Code: 88300, 88305

Our Expert's Advice:

"No charge," is the only way to account for the right true cord biopsy. "You should not charge 88300 [Level I - Surgical pathology, gross examination only] for the right cord submission - the pathologist did not do a gross exam on nothing," Younes says. The report is correct to list 88305 for the left cord biopsy (... larynx, biopsy).