Pathology/Lab Coding Alert

Understanding when tissue samples represent different specimens is the key to correct coding for surgical pathology. But lab personnel say they often find the definition confusing. Just because specimens arrive in different containers, should they be considered separate? Should tissue from different organs always be considered separate specimens?

Its crucial to answer these questions correctly in order to receive fair reimbursement for services provided. Improperly separating tissue into different specimens is considered unbundling, which is the incorrect practice of breaking down a single procedure into its component parts, and billing for additional services. Unbundling can result in denial of a claim, or even charges of fraud. On the other hand, grouping samples together that could be properly identified as separate specimens results in underpayment of claims.

Some guidelines are clearly laid out in the code, says Debbie Siena, HT (ASCP), manager of the histology department of Baylor University Medical Center in Dallas, Texas. For example, because code 88309 reads breast, mastectomywith regional lymph nodes, it would be the only code used for examination of tissue from a modified radical mastectomy. It would not be appropriate to separately code the axillary lymph nodes from this procedure as CPT 88307 (lymph nodes, regional resection). There are a number of other tissues that are specifically grouped in this way, according to Siena, for example uterus with tubes and ovaries (88305-88309), larynx with regional lymph nodes (88309), tonsils with adenoids (88304), multiple hemorrhoids (88304), and multiple fingers or toes from the same hand or foot (88302).

Number of Containers Not Relevant

Part of the confusion stems from tissue samples being submitted to the lab in a manner that is inconsistent with the specimen. For example, a hysterectomy may be performed for uterine leiomyoma (218), but the surgeon may place the incidental tubes and ovaries in a separate container from the uterus. Regardless of the number of containers, 88307 should be reported once because the code specifies uterus, with or without tubes and ovaries.

There are also occasions, however, that the CPT code doesnt specify with or without associated organs, such as the seminal vesicles that are typically removed in a radical resection of the prostate. However, tissues that are normally removed together should be treated as a single unit of service. Unless specifically directed otherwise, these tissues do not require individual examination and pathologic diagnosis, as specified in CPT, so they are considered one specimen. Even if these tissues came to the lab in separate containers, 88309 (prostate, radical resection) should be reported once.

Conversely, separate specimens are sometimes submitted in [...]