Pathology/Lab Coding Alert

Stick to skin-origin codes regardless of depth or size.

No one's happy reporting a skin code when the pathologist examines a large, cancerous skin specimen that has spread to subcutaneous tissue and requires margin evaluation. Those examinations are more work -- so can you use a musculoskeletal code that pays more?

Find the answer as you read on to make sure that you understand the skin-code boundaries. You'll also learn one little trick that might ethically earn your pathologist more pay for those difficult skin specimens.

Focus on 3 Skin Codes

Regardless of size, depth, or neoplastic status, CPT® provides only the following three codes to describe skin-specimen pathology services:

• 88302 -- Level II - Surgical pathology, gross and microscopic examination, skin, plastic repair
• 88304 -- Level III - Surgical pathology, gross and microscopic examination, skin - cyst/tag/debridement
• 88305 -- Level IV - Surgical pathology, gross and microscopic examination, skin, other than cyst/tag/debridement/plastic repair.

Distinguish the three codes by determining if the skin specimen is:

• removed during plastic repair
• a cyst, or skin tag, or skin from debridement
• any other skin specimen.

As long as the operative note indicates that the surgeon removed a skin specimen and the pathologist's findings indicate normal skin or abnormalities that originate in the skin, you'll need to turn to these codes.

Coder tip: You can use the narrative diagnosis or ICD-9 code to determine where the excised lesion originated. "For instance, a squamous cell carcinoma may extend into subcutaneous tissue, but you know that it's a skin specimen because squamous cell arises in the epithelium," says Pamela Biffle, CPC, CPC-P, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Texas. The pathology report should confirm the specimen type.

In other words, the answer to our leading question is "no," you should not use a musculoskeletal code (such as 88307, Level V - Surgical pathology, gross and microscopic examination, soft tissue mass [except lipoma] - biopsy/simple excision), that pays more when the lesion extends into subcutaneous tissue.

Let Modifier 22 Work for Additional Pay

You should never upcode a skin specimen to 88307 because of cancer diagnosis, extreme depth or size, or an unusually difficult and time consuming pathology exam, such as a melanoma specimen requiring margin evaluation.

Opportunity: But you may report the service with modifier 22 (Increased procedural services). Use this modifier to describe a basic CPT® procedure that requires more work than usual for the code, but that you can't accurately describe using another code.

Make sure you provide documentation explaining the unusual circumstances surrounding the procedure. This could include items such as the pathology report, a narrative describing the unusual nature of the procedure, a statement of the time involved relative to the typical time for the procedure, etc. Your documentation must demonstrate medical necessity and the procedure's unusual difficulty.