Pathology/Lab Coding Alert

Surgical pathology Coder beware: Knowing the organ or anatomic site is not enough to determine the level of service. Although using 88300-88309 appears simple just find the specimen in the list under each code looks can be deceiving. Coders won't find the specimens indexed in the CPT manual , either.

"Many organs appear under multiple codes for surgical pathology; some even appear at every level of service," says R.M. Stainton, MD, president of Doctor's Anatomic Pathology in Jonesboro, Ark. For example, "testis," with various modifying terms, is a listed specimen under each of the codes 88302-88309 (Level II through VI Surgical pathology, gross and microscopic examination). "Pathology coders have to understand the many factors that determine the level of service for a particular organ or tissue type," Stainton says.

Surgical Pathology Coding Basics

The unit of service for surgical pathology codes 88300-88309 is the specimen, which CPT defines as "tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis." The service provided for each specimen is "accession, examination and reporting." Except for 88300 Level I Surgical pathology, gross examination only), the work involves gross and microscopic examination of the tissue, including routine staining such as hematoxylin and eosin (H&E). The codes represent ascending levels of physician work.

A list of specimens follows each surgical pathology code descriptor in the CPT manual. Listed specimens should be assigned to the appropriate code. "Only if the specimen is unlisted should it be assigned to a code based on the physician's determination of the level of work involved," Stainton says.

Pathologists and coders must do their part to ensure accurate coding for surgical pathology services. "The pathologist must provide a diagnosis and description of the specimen or specimens," Stainton explains. "Meanwhile, the coder must understand which of these factors, beyond just the name of the organ or anatomic site, will impact code assignment."

Know the Diagnosis Before Coding

Many surgical pathology codes rely not just on the type and extent of tissue the pathologist examines but also on the final diagnosis. "Several tissues are assigned to a different level of surgical pathology depending on whether the diagnosis is neoplastic," says Peggy Slagle, CPC, billing compliance coordinator, University of Nebraska Medical Center in Omaha.

For example, coders should report a uterus submitted with a clinical diagnosis of endometriosis (617.0) as 88307 ( uterus, with or without tubes and ovaries, other than neoplastic/prolapse) if the pathologist's examination confirms the suspected diagnosis. "However, if the pathologist diagnoses adenocarcinoma of the endometrium [182.0, Malignant neoplasm of the corpus uteri, except isthmus] based on the gross and microscopic examination, the coder should report 88309 [uterus, with or without tubes and ovaries, neoplastic]," Slagle says.

Understand the Reason for Excision

The same tissue may also be considered a different specimen and reported as a different level of service depending on the reason for the excision. For example, a fallopian tube removed for sterilization (88302, fallopian tube, sterilization) is coded differently than a fallopian tube removed for a suspected pathology (88305, fallopian tube, biopsy; or fallopian tube, ectopic pregnancy).

"Tissues listed under 88302 are removed with no expected pathology, and submitted for the pathologist to confirm identification and the absence of disease," says Stainton. "If the tissue is indeed disease-free, the specimen is listed as 88302." But in the event of pathologic findings, the coder may find the tissue listed as a specimen under a higher code and should report the service accordingly.

On the other hand, certain tissues are assigned a higher code if they are evaluated for tumor, regardless of the final diagnosis. "For example, for a colon resection from a patient with a history of a malignant polyp, the evaluation is 'for tumor' regardless of the final diagnosis," Stainton says. The correct code would be 88309 ( colon, segmental resection for tumor), not 88307 ( colon, segmental resection, other than for tumor).

Distinguish Between Biopsy and Resection

The same organ or tissue may appear under multiple surgical pathology service codes based on whether the specimen is a biopsy or a resection, and whether the resection is total or partial, and with or without lymph nodes. "To ensure accurate coding, pathologists should clearly define the specimen, avoiding nondescript terms such as 'kidney tissue,' " Stainton says.

Instead, pathologists should describe the tissue using the language of CPT as much as possible, such as "biopsy," "curetting," and "partial resection." "Using this type of terminology in no way compromises the pathologist's reporting, but it assists in ensuring accurate billing and payment for services," Stainton says.

For example, a biopsy or polyp of the small intestine is reported as 88305, while a diverticulum of the small intestine is 88304. But that's not all a resection of the small intestine is reported as 88307 or 88309 (based on whether it is for tumor). "Coders must use specific information documented in the pathology report," Slagle says. "Serious coding errors could occur if the report only indicates "small bowel," even given the size of the specimen and the diagnosis."These errors could cost the practice in either underpayment for services, or fraud charges.

Realize the Extent of Surgical Procedures

Pathology coders also need to know how the surgical description of a procedure corresponds to the surgical pathology specimen list. For example, the surgical description of a breast procedure might include terms such as "modified radical mastectomy," "lumpectomy," or "excisional breast biopsy."

"But the surgical pathology codes are distinguished based on whether the specimen requires microscopic evaluation of surgical margins, the extent of the resection, and the presence or absence of lymph tissue," Slagle says. Report a breast biopsy that does not require microscopic evaluation of surgical margins as 88305 ( breast, biopsy, not requiring microscopic evaluation of surgical margins). For example, use this code for a needle localization biopsy that does not involve examination of margins.

The term "lumpectomy" indicates the surgeon's attempt to remove the entire lesion, and the pathologist would normally evaluate surgical margins. Report this service as 88307 ( breast, excision of lesion, requiring microscopic evaluation of surgical margins) regardless of size. Also report specimens such as "partial mastectomy" or "quadrantectomy" using 88307 ( breast, mastectomy - partial/simple).

Report breast tissue removed with contiguous lymph nodes as 88309 ( breast, mastectomy - with regional lymph nodes). This type of specimen might be described using different names, such as "simple mastectomy with axillary dissection," or "modified radical mastectomy." "If coders remember the principles for assigning breast codes, such as margin or lymph evaluation, they won't be fooled by the many different names used to describe breast specimens," Slagle says.

Note: See the insert for a comprehensive list of surgical pathology codes that are broken down alphabetically to make it simpler for you to identify the surgical pathology specimen and code.