Pathology/Lab Coding Alert

Question: Our pathologist examined a liver biopsy and used a trichrome stain for fibrosis and a reticulum stain, resulting in a diagnosis of cirrhosis. How should we code the case?

Michigan Subscriber

Answer: Report the liver biopsy as 88307 (Level V -- Surgical pathology, gross and microscopic examination, liver biopsy -- needle/wedge). Because the pathologist examines two stains for reasons unrelated to microorganisms, report 88313 x 2 (Special stains; Group II, all other [e.g., iron, trichrome], except immunocytochemistry and immunoperoxidase stains, including interpretation and report, each).

List the diagnosis as 571.5 (Cirrhosis of liver without mention of alcohol).

Code additional conditions, if known: Note that if the cirrhosis is related to viral hepatitis, you should code that condition first (070.xx, viral hepatitis). If the pathologist has information regarding patient alcohol abuse, choose 571.2 (Alcoholic cirrhosis of liver). If the cirrhosis is due to biliary disease, list 571.6 (Biliary cirrhosis).

Correction: The answer to reader question "Deconstruct Panels to Find Most Comprehensive" on page 71 of Pathology/ Lab Coding Alert Vol. 11. No. 9 contains a typographical error referring to 80046 instead of the code properly identified elsewhere in the answer -- 80076. We apologize for any inconvenience.

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.