Pathology/Lab Coding Alert

Should you throw the ‘specimen’ convention out the window?

For surgical pathology ancillary procedures, “the specimen” is the universal unit of service -- or is it? If you could report one more immuno stain for an additional block, your practice would gain an extra $98.15 in pay (based on the Medicare physician fee schedule national amount for global 88342 using conversion factor 36.0846).

The Correct Coding Initiative (CCI) Policy Manual version 15.3 opens the door to just such a possibility. The manual allows that you may report additional units of special stain codes for “additional block(s).”

Pinpoint the Codes

The CCI policy manual makes the surprise statement about coding per block with reference to the following codes:

• 88312 -- Special stains; Group I for microorganisms (e.g., Gridley, acid fast, methenamine silver), including interpretation and report, each

• 88313 -- … Group II, all other (e.g., iron, trichrome), except immunocytochemistry and immunoperoxidase stains, including interpretation and report, each

• 88342 -- Immunohistochemistry (including immunoperoxidase), each antibody

• 88360 -- Morphometric analysis, tumor immunohistochemistry (e.g., Her-2/neu, estrogen receptor/progesterone receptor), quantitative or  semiquantitative, each antibody; manual

• 88361 -- … using computer-assisted technology.

“Each of these codes lists the unit of service as each ‘stain’ or ‘antibody,’” explains Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

Distinguish Specimen/Block/Slide

But each stain or antibody goes on a slide. Does that mean you should code each stain per slide? “Absolutely not -- you should never code special stains per slide,” Slagle says. To understand the reasoning, you need to know the distinction between specimen, block, and slide.

Specimen is 88300-88309 unit of service: When you report a tissue pathology exam (88300-88309), the unit of service is the specimen, according to CPT instruction. CPT defines a specimen as “tissue or tissue(s) that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis.” That might mean a breast biopsy, a colon resection, or any other of the hundreds of listed (and some unlisted) tissues that your pathologist might examine for pathologic diagnosis.

You may have blocks: “Depending on the size of the  tissue specimen and the detail needed to evaluate it, the pathologist may subdivide a specimen into multiple ‘tissueblocks’ for processing,” explains Ernest J. Conforti, MS, MBA, SCT(ASCP)MT, director of patient financial services for North Shore-Long Island Jewish Health System, headquartered in Great Neck, N.Y.

Then you get slides: Whether the lab processes the entire specimen as one paraffin block or subdivides the specimen into multiple paraffin blocks, the next step is slicing the block(s) into microscope slides. “The lab personnel may apply special stains to some of the slides at this point in processing,” Conforti says.

See What CCI Says About Stain Unit of Service

In a departure from common coding practice, the CCI manual states, “If it is medically reasonable and necessary to perform the same stain on more than one specimen or more than one block of tissue from the same specimen, additional units of service may be reported for the additional specimen(s) or block(s).”

Don’t code per level or slide: The manual goes on to clarify that if the lab cuts multiple levels from a single tissue block and stains each level with the same stain, you should not report additional units of service for the stain.

You should report only one unit of service “for the stain on multiple levels from the single tissue block,” according to the CCI manual. Since the lab may prepare multiple slides from different levels, logic extends the restriction of not coding per level to not coding per slide.

Resource: You can access the CCI policy manual at www.cms.hhs.gov/NationalCorrectCodiNitEd/01_overview.asp.

Know Coding Convention

According to coding convention supported by the AMA and the College of American Pathologists, the unit of service for special stains is per stain, per specimen. The unit of service is not per stain per block.

For instance: The Oct. 2002 CAP Today, states that correct coding for an IHC stain applied to two blocks of a single sentinel lymph node specimen is one unit of 88342.

Caution: “Although it appears that you can now report special stains to Medicare per stain per block, I would proceed with caution and document the CCI resource and the new lab policy in the lab compliance manual,” Conforti says. You should not assume that other payers will adopt this Medicare convention.