Pathology/Lab Coding Alert

If you know the final pathologic diagnosis, put it on your Medicare claim. CMS clarifies this and other ICD-9 coding rules for diagnostic test claims in program memorandum AB-01-144. These instructions refer to lab services paid under the Medicare Physician Fee Schedule, not tests paid under the Clinical Diagnostic Laboratory Fee Schedule.

1.If the pathologist makes a definitive diagnosis based on the results of the diagnostic test, the testing facility and the pathologist should code that diagnosis. "The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis," according to the memorandum. "I advise against adding a clinical diagnosis ICD-9 code to a definitive pathologic code unless the two together make a stronger case for medical necessity than the pathologic diagnosis alone," says Dennis Padget, MBA, CPA, FHFMA, president of Padget & Associates, a pathology financial and compliance consulting firm in Simpsonville, Ky.

2."If the diagnostic test did not provide a diagnosis or was normal, the interpreting physician should code the sign(s) or symptom(s) that prompted the treating physician to order the study," the memorandum states.

3."If the results of the diagnostic test are normal or non-diagnostic, and the referring physician records a diagnosis preceded by words that indicate uncertainty (e.g., probable, suspected, questionable, rule out, provisional or working), then the interpreting physician should not code the referring diagnosis. Rather, the interpreting physician should report the sign(s) or symptom(s) that prompted the study. Diagnoses labeled as uncertain are considered by the ICD-9-CM coding guidelines as unconfirmed and should not be reported. This is consistent with the requirement to code the diagnosis to the highest degree of certainty," the memorandum states.

Put the Rules Into Practice

Test your skill at applying these principles by coding the following scenarios, then compare your ICD-9 code to what the experts say.

Scenario 1:

Question: A surgeon submits a cheek tissue specimen for pathology, identifying it only as a "skin lesion." The pathologist performs an examination (88305, Level IV -Surgical pathology, gross and microscopic examination, skin, other than cyst/tag/debridement/plastic repair) and reports to the surgeon findings of basal cell carcinoma. Which ICD-9 code should the pathologist report?

Answer: Coding to the highest degree of certainty requires the pathologist to report the final diagnosis of 173.3 (Other malignant neoplasm of skin; skin of other and unspecified parts of face). Being a physician, the pathologist can assign a diagnosis and should report the specific findings rather than the surgeon's nonspecific reason for ordering the test. CMS instruction states, "It is appropriate for coders to code based on the physician documentation [the pathologist's report, in this instance] available at the time of code assignment."

Scenario 2:

Question: A urologist sends a urine specimen to the cytology lab with the narrative diagnosis "hematuria" and "rule-out bladder cancer." Following the cytopathology exam such as 88104 (Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpre -tation), the pathologist issues a report stating, "No malignant cells." How should you report the diagnosis for this service?

Answer. "Do not report the 'rule-out' condition [188.9,

Malignant neoplasm of bladder; bladder, part unspecified] because neither the ordering physician nor the pathologist has confirmed a diagnosis of bladder cancer," Padget says. "But because 'No malignant cells' is not a definitive pathologic diagnosis, you can't code it either. Instead, you should report the symptom that prompted the urologist to order the cytopathology exam - hematuria (599.7)."

Scenario 3:

Question: A physician orders a complete blood count (CBC) for a patient who presented at the office complaining of fatigue. The CBC findings show low hemoglobin and hematocrit, indicating anemia. Which code(s) should the lab report?

Answer: The lab should report the CBC using the appropriate CPT code such as 85025 (Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count) for an automated CBC.

"Because this is a clinical lab test with no Medicare Part B physician component, you cannot report anemia [285.9] as the diagnosis, even though it is indicated by the results," Padget says.

"According to CMS instructions that take effect Oct. 1, the lab should report the ordering diagnosis - fatigue [780.79] - on its claim for the CBC," Padget says. The patient's physician will assign the final diagnosis based on the lab test results and other clinical findings.