Pathology/Lab Coding Alert

"Clinical labs and anatomic pathologists use special stains to aid in microscopic examination of tissues or cells, but they shouldnt necessarily report the same codes for the same stain. Coders must know which CPT Codes to use based not only on the type of stain but also on the stain substrate and the reason for the procedure. Many special stain processes are described by 85535-85536, 87205-87207 and 88312-88313. Without properly applying these codes, laboratories may sacrifice payment for legitimate staining services, says William Dettwyler, MT-AMT, coding analyst for Health Systems Concepts, laboratory coding and compliance consultants in Longwood, Fla.

CPT 88312 -88313

Two special stain codes appear as add-on codes in the CPT surgical pathology section: 88312 (special stains [list separately in addition to code for surgical pathology examination]; group I for microorganisms [e.g., Gridley, acid fast, methenamine silver], each) and 88313 (... group II, all other [e.g., iron, trichrome], except immunocytochemistry and immunoperoxidase stains, each). In their most straightforward application, these codes describe the special staining of any surgical pathology tissue specimen. For example, an acid fast stain carried out on a transbronchial lung biopsy for diagnosis of disease such as tuberculosis would be reported as 88312, in addition to the surgical pathology service (88305, level IV surgical pathology, gross and microscopic examination, lung, transbronchial biopsy). Similarly, a trichrome stain to evaluate fibrosis observed in a liver biopsy (88307) is reported as 88313.

Despite the fact that 88312 and 88313 are add-on codes in surgical pathology, they also describe special staining services for specimens other than surgical pathology tissues. For example, if a trichrome stain for ova and parasites is carried out on a direct smear from a stool sample, the service is reported as 88312. There is no code in the microbiology section for this stain, so the service must be reported with one of the special stain codes from surgical pathology, Dettwyler says. A directional note in the microbiology section of the CPT manual states, For complex special stains, see 88312, 88313.

Another point coders find confusing about the ova and parasites stain is the fact that a trichrome stain is reported with 88312, even though trichrome is listed as an example under 88313. But in the ova and parasites stain, the trichrome is used to identify microorganisms, and should therefore be listed as 88312 because its definition lists group I for microorganisms, Dettwyler says. The trichrome stain described by 88313 is a tissue dye technique used to highlight connective tissue, muscle, cytoplasm and nuclei, and is therefore considered a group II stain.

Although CPT directs the use of 88312 or 88313 for special stains on specimens other than tissue, some laboratories have reported denials from both Medicare and third-party payers. Sometimes the problem is that a clinical laboratory has certification for microbiology and parasitology, but not for anatomic pathology, Dettwyler says. Then when the lab reports codes from the surgical pathology section, such as 88312 or 88313, payment is denied. Labs can appeal the denials and ask the carrier to add these special stain codes to those allowed under the labs certification specialty.

Yet another use of 88313 for nonsurgical specimens is the reporting of iron stains for bone marrow aspiration requiring physician evaluation. Although there are separate codes for iron stains for blood and bone marrow smears (85535-85536), a note following these codes directs coders, For iron stains on bone marrow or other tissues with physician evaluation, use 88313. Further, CPT directs coders to special stain codes 88312 and 88313 in a note under the bone marrow aspiration codes (85095 and 85097).

For example, a pathologist may evaluate bone marrow aspiration smears, plus a cellblock made from the clot, and also interpret an iron stain for the diagnosis of iron-deficiency anemia (280). These services are reported as 85097 (bone marrow; smear interpretation only, with or without differential cell count), 88305 ( cell block, any source) and 88313x2 for the iron stain if it is carried out on both the aspirate and the cell block.

Codes 85535-85536

Hematology code 85535 (iron stain [RBC or bone marrow smears]) describes technologist appraisal of sideroblastic or reticuloendothelial bone marrow iron stores. Code 85536 (iron stain, peripheral blood) was added in CPT 2001 to report microscopic analysis by a medical technologist for abnormal iron accumulations in peripheral blood. Because the wording allows reporting a red-blood-cell iron stain with either code, 85536 should be used for peripheral blood smears, and 85535 reserved for RBCs other than peripheral blood.

For example, if a physician suspects sideroblastic anemia and requests an iron stain on peripheral blood, the stain is reported as 85536. The stain may be reported in addition to the pathologists evaluation of the smear (85060, blood smear, peripheral, interpretation by physician with written report).

CPT 2001 also added a note following 85536 directing coders to use 88313 for physician evaluation of iron stains on bone marrow or other tissues. For instance, a pathologist may evaluate a bone marrow biopsy (85102, bone marrow biopsy, needle or trocar) and decalcify the specimen (88311, decalcification procedure [list separately in addition to code for surgical pathology examination]) to permit an iron stain evaluation (88313) of the bone marrow.

Codes 87205-87210

The 87205-87210 family of codes reports special microbiology stains for direct smears from various sources. The stains are 87205 (smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types), 87206 ( fluorescent and/or acid fast stain for bacteria, fungi, parasites, viruses or cell types) and 87207 ( special stain for inclusion bodies or intracellular parasites [e.g., malaria, coccidia, microsporidia, cytomegalovirus, herpes viruses]). The stain substrate includes direct smears from sources such as blood, urine, stool, sputum, synovial fluid, cerebrospinal fluid (CSF) or vaginal smears.

Codes 87205 -87207 describe special stains used to indicate the presence of disease-causing organisms in direct smears, says Kathleen Ohrt, MT (ASCP), SM, microbiology technical specialist at Beebe Medical Center in Lewes, Del. These tests are often run concurrent with a culture. Although some of the same stains may be used to identify cultured organisms, the 87205 family of codes should not be used for cultures, Ohrt says. Stains and other tests to identify cultured organisms are included in the codes for presumptive and definitive identification, she says.

Some clinical examples illustrate how to use codes 87205-87210:

For a urine or vaginal smear evaluated for bacteria using a Giemsa stain, report 87205.

For a vaginal smear evaluated for Trichomonas or Monilia using a wet mount such as KOH or saline preps, report 87210 (wet mount for infectious agents [e.g., saline, India ink, KOH preps]).

For a Giemsa stain of a peripheral blood smear for suspected malaria, report 87207. Regardless of the fact that Giemsa stain is listed under 87205, in this case it is used as a special stain for the sporozoan malarial organism, Plasmodium, rather than a bacteria or fungi, and should be reported as 87207. Note that the peripheral blood is typically concentrated for this stain, which is separately reportable as 87015 (concentration [any type], for infectious agents).

Report an acid-fast bacilli (AFB) stain of a sputum smear with 87206. This may be an acid fast stain, or a fluorescent stain, Ohrt says. Typically, the sputum is also concentrated, which is reported separately according to CPT direction for thick smear preparation, use 87015.

For a synovial fluid smear, either a Gram stain for bacteria, or Giemsa or Wright stain for cells should be reported with 87205.

Gram staining of a direct CSF smear to indicate the presence of bacteria such as meningococci is reported as 87205. The CSF would typically be cultured at the same time, reportable as 87070 (culture, bacterial; any other source except urine, blood or stool, with isolation and presumptive identification of isolates), Ohrt says.

Special staining of a direct smear from a herpetic vesicle for inclusion bodies, such as the Tzanck stain for herpes simplex virus, would be reported with 87207. Note that this is the only code from this family listed in the physician fee schedule with modifier -26 (professional component). If a pathologist provides a professional interpretation and report of a special stain for inclusion bodies or intracellular parasites, 87207-26 should be reported for the service, Dettwyler says.

Remember that not all microbiology staining of direct smears is reported with 87205-87210. A note associated with these codes in the CPT manual directs coders, For complex special stains, see 88312, 88313. Recall the earlier example of a stool smear trichrome stain for ova and parasites reported with 88312.

Because CPT directs coders to special stain services listed in divergent parts of the pathology and laboratory section, coders should be familiar with all of these codes."