Pathology/Lab Coding Alert

Question: If our pathologist performs touch preps on four separately identified surgical margins for a breast lumpectomy and consults with the physician during surgery, then prepares permanent sections from those same margins and uses them for the surgical pathology exam, can we report the touch preps in addition to the surgical pathology exam using modifier -59? How can we consider the touch preps and surgical pathology exam to be from "different sources" when they are from the same tissue?

Pennsylvania Subscriber

Answer: Based on the National Correct Coding Initiative edit barring you from reporting touch preps (88161, Cytopathology, smears, any other source; preparation, screening and interpretation) with surgical pathology code 88307 (Level V - Surgical pathology, gross and microscopic examination, breast, excision of lesion, requiring microscopic evaluation of surgical margins), you generally should not report these codes together. NCCI, however, allows you to override this edit pair with modifier -59 (Distinct procedural service) under certain conditions described by CPT as "different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury."
 
The College of American Pathologists (CAP) objected to CMS about the touch prep/surgical pathology edit pairs because of situations such as you have described, but CMS refused to remove the edit. CMS does allow you to bypass the edit when the pathologist renders independent diagnoses on separate specimens.
 
If the pathologist provides (and documents) individual diagnoses for each touch prep and reports the findings to the surgeon during surgery, then later provides a separate diagnosis for the surgical pathology exam, you've met half of CMS' requirement. Although experts debate whether you have "separate specimens," the touch prep examination clearly represents a "different session" or "different procedure," as the CPT explanation of modifier -59 requires. 
 
Although coding principles indicate that you can report 88161 x 4 for the touch preps, 88329 (Pathology consultation during surgery) for the consultation, and 88307 for the surgical pathology exam, the debate surrounding these NCCI edits gives some coders pause. Clearly, you can report 88329 with 88161 for the intraoperative pathology consultation with touch preps.
 
But because CMS states that you shouldn't report 88161 with 88307 for the same specimen, you may want to consult your local Medicare carrier for a written ruling on this issue, and use your understanding of coding principles to argue your case.