Pathology/Lab Coding Alert

Question: Our pathologist receives 11 to 14 muscle and nerve biopsy specimens and performs frozen section histochemical staining on each. Can we bill 88314 multiple times?

Iowa Subscriber

Answer: Yes, you can bill multiple units of +88314 (Special stains; histochemical staining with frozen section[s], including interpretation and report [List separately in addition to code for primary procedure]) if the pathologist evaluates the stain on multiple specimens.

In your example of muscle and nerve biopsies, you should report 88305 (Level IV -- Surgical pathology, gross and microscopic examination, muscle, biopsy or nerve, biopsy) times the number of specimens your pathologist individually evaluates and diagnoses. If the pathologist performs a special histochemical frozen section stain on each of 11 biopsies, you should list +88314 x 11.

The unit of service for +88314 is the same as other special stain -- one unit for each unique stain on each separate specimen.

For instance, if the pathologist ran a Congo red, periodic acid Schiff (PAS) and trichrome on snap-frozen sections from each of two different muscle biopsies, you should report 88314 x 6. Document carefully: Make sure each biopsy is separately identifiable based on the surgeon's documentation and based on the pathologist's unique diagnosis for each. You shouldn't list multiple biopsies (88305) or multiple special stains without adequate documentation.

Reader Questions and You Be the Coder were prepared with the assistance of R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.