Pathology/Lab Coding Alert

Use this clinical example to sharpen your skills

You're faced with a pathology report for a radical prostatectomy. Can you find every procedure performed and assign the appropriate codes? Try coding the following pathology report, then see if you would have captured all the payment your lab deserves.
 
History: The patient is 73 years old, diagnosed with prostatic adenocarcinoma.

Procedure: Radical prostatectomy with bilateral pelvic lymph node dissection.

Specimens:

A. Bladder neck margin for frozen section
B. Urethral margin for frozen section
C. Radical prostatectomy
D. Left pelvic lymph nodes
E. Right pelvic lymph nodes

Gross Description

A. This is a 0.5-cm piece of tissue that is submitted for frozen section evaluation and then resubmitted for routine processing with the designation FSC-A.

Frozen section diagnosis: Bladder neck margin: No tumor identified

B. This is a 0.5-cm piece of tan tissue that is submitted for frozen section evaluation and then resubmitted for routine processing with the designation FSC-B

Frozen section diagnosis: Urethral margin: No tumor identified

C. This is a prostate with attached seminal vesicles. The prostate is inked and then serially sectioned by multiple parallel knife cuts. Areas of yellow, gritty, hard tissue are identified on the left side of the prostate. The right side of the prostate is nodular. Multiple sections of the left prostate are submitted in cassettes C1, C2 and C3. Sections of the right prostate are submitted in cassettes C4, C5 and C6. Sections of the left seminal vesicle are submitted in cassette C7, and sections of the right seminal vesicle are submitted in cassette C8. The junction of the left seminal vesicle and prostate is submitted in cassette C9, and the junction of the right seminal vesicle and prostate is submitted in cassette C10.

D. The left pelvic lymph nodes consist of palpable nodules in fat. It is dissected for lymph nodes. Five are identified, and they range in size from 0.3 to 0.8 cm. The nodes are sectioned and separately submitted in cassettes D1, D2, D3, D4 and D5.

E. The right pelvic lymph nodes consist of palpable nodules in fat. It is dissected for lymph nodes. Four are identified, and they range in size from 0.9 to 1.1 cm. The nodes are sectioned and separately submitted in cassettes E1, E2, E3 and E4.

Microscopic Examination: Microscopic examination performed

Diagnosis:

A. Bladder neck margins: benign bladder neck tissue
B. Prostatic urethral margin: benign prostatic urethra
C. Prostate: adenocarcinoma, Gleason's combined score of 6 (primary grade 3 + secondary grade 3)
    1. Tumor does not extend to inked surgical margins
D. Left pelvic lymph nodes: five lymph nodes with one altered by metastatic carcinoma
E. Right pelvic lymph nodes: No tumor identified.

Does Your Coding Match the Experts'?

Frozen section examination of bladder neck margin -- 88331 (Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen)

Frozen section examination of urethral margin -- 88331

Prostate with attached seminal vesicles -- 88309 (Level VI - surgical pathology, gross and microscopic examination, prostate, radical resection)

Left pelvic lymph node dissection -- 88307 (Level V - surgical pathology, gross and microscopic examination, lymph nodes, regional resection)

Right pelvic lymph node dissection -- 88307

Bladder neck margin examination -- 88305 (Level IV - surgical pathology, gross and microscopic examination, urinary bladder, biopsy)

Prostatic urethra margin examination -- 88305 (... urethra, biopsy).

-- "Test Your Prostate-Coding Savvy" was prepared with the assistance of R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.