Pathology/Lab Coding Alert

Know when to bundle and when to separately code.

If you get cold feet about separately charging for lymph nodes taken at the time of a larger resection, you're not alone. Unclear bundling rules make plenty of coders live by "better safe than sorry," and leave legitimate lymph node pay on the table.

Let our experts walk you through four guidelines to determine when you can separately bill lymph node(s), and which code(s) you should report.

Remember: When conditions warrant separately charging for lymph nodes, you should choose the proper code from the following three options:

• 88305 -- Level IV -- Surgical pathology, gross and microscopic examination, lymph node, biopsy
• 88307 -- Level V -- Surgical pathology, gross and microscopic examination, lymph nodes, regional resection
• 88307 -- ... sentinel lymph node.

Tip 1: Sentinel Nodes Stand Alone

"A sentinel lymph node never has to be bundled with the primary specimen," says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc. and publisher of the Pathology Service Coding Handbook, in The Villages, Fla. That's because pathologists only perform this service when the surgeon submits a uniquely identified sentinel node (first draining node near the tumor) for in depth examination involving serial sectioning and histochemical staining to identify micrometastases.

Bottom line: The lymph node bundling rules in the following tips 2-4 don't apply to sentinel nodes.

Tip 2: Obey Instructions That Bundle Lymph Nodes

When the CPT® definition includes lymph nodes, you know you can't report 88305 or 88307 for lymph node biopsy or resection in addition to the primary specimen. Make sure you're familiar with the following specimens that include the lymph node exam -- by definition:

• 88309 -- Level VI -- Surgical pathology, gross and microscopic examination, breast, mastectomy - with regional lymph nodes
• 88309 -- ... larynx, partial/total resection - with regional lymph nodes

"You should never unbundle lymph nodes from a radical breast mastectomy or laryngectomy specimen, except for a sentinel lymph node," says R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.

"On the other hand, don't read more into a case than is actually there" Padget cautions. "For example, if you get a lymphadenectomy with a breast lumpectomy specimen, the regional nodes don't have to be bundled, because they're not a customary component of a partial mastectomy."

Look beyond definitions: Coding authorities advise that there are a couple of additional specimens that should regularly include the associated lymph nodes even though the CPT® definition doesn't state "with regional lymph nodes." According the College of American Pathologists in CAP Today, July 1999, you should bundle associated lymph nodes with the following specimens:

• 88304 -- Level III -- Surgical pathology, gross and microscopic examination, gallbladder
• 88307 -- ... colon, segmental resection, other than for tumor
• 88309 -- ... colon, segmental resection for tumor
• 88309 -- ... colon, total resection

Exception: If the surgeon submits a separately identified lymph node or regional lymph resection from a different body site, you can code for that work in addition to the preceding specimens. For instance, pelvic and retroperitoneal lymph nodes are not typically part of a cholecystectomy or colectomy surgical procedure, so you could separately code one of those (88305 or 88307) in addition to the primary specimen.

Tip 3: Follow the 'Attached' Rule to Finalize your No-Separate-Lymph List

In addition to the preceding "firm" list of specimens that bundle lymph nodes, coding authorities provide direction about when you should bundle lymph nodes with other specimens.

Rule: If lymph nodes are (ordinarily) attached to the primary specimen, you should not separately code for the lymph node exam. You'll find this rule published in CPT® Assistant, Fall  1993, and CAP Today, July 1999. In other words, bundling "attached" lymph nodes is a long-standing coding convention supported by authoritative sources.

The next step is to understand which specimens "ordinarily" have attached lymph nodes that you shouldn't unbundle.

Bundle lymph nodes with these: The following specimens may arrive in pathology with attached lymph nodes, meaning that you should bundle them for coding purposes:

• 88307 (... liver, partial resection) includes attached hepatic, cystic and phrenic lymph nodes
• 88309 (... lung - total/lobe/segment resection) includes attached hilar and intrapulmonary nodes
• 88309 (... pancreas, total/subtotal resection) includes attached pancreatic and pyloric lymph nodes
• 88305 (... spleen) includes attached splenic lymph nodes

Caveat: Although the pathologist may receive the preceding specimens with attached nodes not identified by the surgeon in any way, you may not always need to bundle the lymph nodes. "For these specimens, if the surgeon individually identifies -- by labeled container, mention on the requisition, or by other means -- the associated lymph nodes, you can separately charge for them using the appropriate lymph code (88305 or 88307)," Padget says.

Tip 4: Don't Miss Lymph Pay with Common Specimens

"Many surgical specimens don't ordinarily come to pathology with attached lymph nodes," Stainton says. For these specimens, you can separately charge for lymph nodes, even if the surgeon submits them in the same container.

Many "non-attached-lymph" specimens are self-evident, such as bone specimens or biopsies that don't involve surrounding tissue. To help you zero in on other common specimens that don't ordinarily include lymph nodes in the primary specimen code, see "'Clip and Save' Brings Home Lymph Node Pay" on page 60.

Incidental node(s) exception: "Whenever the pathologist finds a lymph node or two 'hiding' in the tissue attached to the primary specimen with no indication that the surgeon removed the node(s) intentionally, you should bundle the node(s) with the primary specimen code," Padget says.