Pathology/Lab Coding Alert

Downcoding and bundling can cost you cash

When your pathologist examines a stomach resection with associated tissue--like peritoneum, lymph nodes or spleen--you could be missing out on potential pay.
 
A surgeon might remove multiple organs or portions of organs, leaving pathology coders to struggle with what constitutes an individual specimen. “Complex surgical specimens are especially susceptible to either underreporting or bundling errors,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services, an independent pathology laboratory in Jonesboro, Ark.

To help you avoid these pitfalls for gastrectomy coding, just answer these three questions to ensure rightful compensation for your services:

1. Is the stomach removed for cancer?

CPT lists two codes for partial or total stomach resection: 88307 (Level V--Surgical pathology, gross and microscopic examination, stomach--subtotal/total resection, other than for tumor) and 88309 (Level VI--Surgical pathology, gross and microscopic examination, stomach--subtotal/total resection for tumor).

Key: “The difference between the two codes is whether the resection is for tumor or any other reason,” says Pamela Younes, MHS, HTL (ASCP), CPC, PA (ASCP), assistant professor at Baylor College of Medicine in Houston. That means you need to know the final diagnosis, which you should find in the pathologist’s report. Generally, you will report 88307 or 88309 based on whether the resection specimen is a neoplasm.

For instance: If the pathologist diagnoses adenocarcinoma (151.x, Malignant neoplasm of stomach), you should report the stomach resection specimen as 88309. But if the pathologist examines a normal partial gastrectomy from a bariatric surgery such as 43845 (Gastric restrictive procedure with partial gastrectomy ...), you should list the pathologist’s work as 88307.

Opportunity: Even if the pathologist does not find cancer in the current stomach resection, you may be able to report the specimen exam as 88309. “If the patient has a confirmed cancer diagnosis from a prior stomach biopsy, you should report the pathologist’s work for the stomach resection as 88309 regardless of the final diagnosis,” Younes says. That’s because the pathologist examines the specimen “for tumor,” which requires more work and fits the 88309 definition.

2. Are other tissues separate ‘listed specimens’?

The pathologist may receive a gastrectomy specimen with several associated tissues such as omentum, lymph nodes, duodenum and spleen. You need to know when to bundle tissues with the stomach specimen, and when to report them separately. “In most cases, when the pathologist performs separate examination and diagnosis of a tissue that CPT lists as a distinct surgical-pathology specimen, you should assign a separate procedure code in addition to the code for the gastrectomy,” Younes says.

Don’t miss: Even if the surgeon submits all the tissue together in one container, you may report separate procedure codes for individual specimens based on the pathology report and CPT guidelines.

Exception: Despite the fact that regional lymph nodes are a CPT-listed specimen (Level V--Surgical pathology, gross and microscopic examination, lymph nodes, regional resection) and the pathologist provides a distinct examination and diagnosis, you should not code separately for the service.

“Many complex surgical pathology specimens, such as a gastrectomy, always include closely associated lymph nodes, and you should consider them part of the specimen,” Younes says. For certain resections, such as mastectomy and larynx, CPT specifically states, “with regional lymph nodes,” but the principle of including associated lymph applies even when CPT does not specifically say so.

The fall 1993 CPT Assistant states, “In coding for surgical pathology level VI (88309) specimens, the general policy is that lymph nodes are not to be separately coded when the nodes are a part of the resected 88309 specimen.”

Pitfall: You may see the pathologist’s diagnosis of a surgical margin that mentions esophagus or small intestine. “The surgical margin is part of the primary stomach specimen,” Younes says. When it’s a margin, you should not separately code for the esophagus or duodenum even though each is a listed specimen in CPT and the pathologist records a diagnosis.
 
3. Why are other tissues removed?

Once you determine that you have separate specimen(s) in addition to the stomach, you need to learn more about them so that you can assign the correct code(s). “Because CPT lists specific tissue types under multiple surgical-pathology codes, you have to determine what the tissue is and why the surgeon removed it,” Younes says.

For example, CPT lists “skin” under three codes:

• 88302--Level II--Surgical pathology, gross and microscopic examination, skin, plastic repair

• 88304--Level III--Surgical pathology, gross and microscopic examination, skin - cyst/tag/debridement

• 88305--Level IV--Surgical pathology, gross and microscopic examination, skin, other than cyst/tag/debridement/plastic repair.

If the pathologist examines a skin specimen that the surgeon submits with the gastrectomy, how should you code it? You have to know if the specimen is a skin lesion for biopsy (88305), or a scar revision (88302) because the surgeon entered through a past incision.