Pathology/Lab Coding Alert

Reporting by the book rather than with an under-standing of coding principles could result in anatomic pathology practices losing money. No cases highlight this problem better than coding for pathology examination of gynecological surgical specimens.

Capturing reimbursement for evaluating hysterectomy specimens requires knowledge of what constitutes a specimen, as well as an understanding of the patients clinical history and the final pathological findings, says R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services, an independent pathology laboratory in Jonesboro, Ark.

Principles of Surgical Pathology Coding

Any surgical pathology service (88300-88309) includes accession, gross and microscopic examination (except 88300, which is gross only), and reporting of the findings and diagnosis to the treating physician. The codes describe a series of progressively more complex procedures for evaluating tissue pathology. Each code is considered a higher level of service than the preceding code (levels I through VI), meaning that more work is involved, and more reimbursement is expected. The unit of service for these codes is the specimen, and each code includes an extensive list of tissue types that would appropriately be assigned to that code. The specimen lists are based on the average amount of work for evaluating each type of tissue. Because they represent an average, pathologists may find any given evaluation to be more or less difficult than the norm. Despite that variation, pathology coders should report the appointed code, and assigning a specimen to a higher level of service because it was unusually large or difficult would be inappropriate, Stainton says.

For types of tissue that are not included in any specimen list, pathologists are to assign the code based on the amount of work involved in the examination. The level of work should be comparable to the work involved in evaluating other specimens listed for that code, Stainton says.

Properly Identify the Specimen

Many surgical pathology coding errors stem from the difficulty in determining what constitutes the specimen, says Stephen Yurco III, MD, partner and pathologist at Clinical Pathology Associates in Austin, Texas. These errors can involve either under- or over-reporting the service, he says. Undercoding can clearly cost a practice money, but so can upcoding if it means the practice is committing fraud.

CPT Codes states: A specimen is defined as tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis. If separate specimens are submitted from the same patient on the same day, then each should be assigned a separate code. That principle may be easy enough to apply if the separate specimens are a gallbladder (88304) and a mole (88305). But it can become complicated in surgical procedures such as various types of hysterectomies.

Coding for Hysterectomy Clinical Examples

Case 1: A 38-year-old childless woman presents with left abdominal cramping. Both her mother and her aunt developed ovarian cancers in their early 60s, and she is quite worried that her pain may be related to this history. The patient took oral contraceptives for six years. She menstruates normally and has no other symptoms. The physician performs a pelvic examination and finds a unilateral palpable adnexal mass. Presence of a tumor is confirmed with transvaginal ultrasound, and a preoperative diagnosis is made indicating an ovarian tumor (236.2).

The patient is scheduled for a recheck in six weeks, and the mass remains. Surgery is scheduled, and based on the appearance of the ovary, the surgeon requests a pathology consultation (88329) including evaluation of frozen sections (88331). The surgeon completes a salpingo-oophorectomy, removing the neoplastic left ovary and associated fallopian tube. The pathologist examines the specimen, reporting a malignant neoplasm (183.0). The service is coded 88307 (level V surgical pathology, gross and microscopic evaluation, ovary with or without tube, neoplastic).

The surgeon proceeds with a hysterectomy due to concerns of metastatic disease. A total abdominal hysterectomy resects the uterus, cervix and remaining ovary and fallopian tube. Additionally, the surgeon carries out an appendectomy, left pelvic para-aortic lymph node sampling and omentectomy of the peritoneum surrounding the uterus.

Because metastasis was found, the pathologist reports 88309 ( uterus, with or without tubes and ovaries, neoplastic) for the evaluation of the hysterectomy specimen, including the uterus and incidental peritoneum and ovary/fallopian tube, based on the findings of metastatic disease (198.82). The appendectomy is reported as 88302 ( appendix, incidental), and sampling of the lymph nodes as 88307 ( lymph nodes, regional resection). The pathology examination also includes tissue immunoperoxidase stains, which are reported as 88342 for each antibody (immunocytochemistry ).

Notice that the coding for pathology services requires an understanding of the clinical history, as well as the diagnosis, Yurco says. For example, the left ovary and fallopian tube was the primary specimen, and the service for evaluation was reported as 88307. However, because the right ovary and fallopian tube were removed incidental to the hysterectomy and showed no distinct pathology, no separate code was reported for their evaluation. Rather, the ovary and tube are bundled with the larger hysterectomy specimen and reported as 88309, which states with or without tubes and ovaries in its definition. Understanding what constitutes a specimen is the key to coding this scenario correctly, Yurco says. When an ovary is submitted for individual examination and pathologic diagnosis, as opposed to incidental to the uterus, it should be reported separately, he says.

The code selection depends on the pathologic diagnosis. Had either the ovary or uterus been diagnosed as non-neoplastic, the procedure code would be different. For the evaluation of a non-neoplastic ovary, the pathologist would have reported 88305 ( ovary with or without tube, non-neoplastic) rather than 88307. Similarly, a non-neoplastic uterus would be reported as 88307 ( uterus, with or without tubes and ovaries, other than neoplastic/prolapse) rather than 88309.

Case 2: A 35-year-old patient visits her physician complaining of excessively heavy menstrual bleeding (626.2). An ultrasound is scheduled, and demonstrates a thickening of the endometrium (621.8).

Based on ultrasound findings and clinical history, an endometrial biopsy is carried out in an outpatient setting. The pathologist examines the biopsy, reports 88305 ( endometrium, curettings/biopsy), and reports the histologic findings of endometrial adenocarcinoma, clinical stage one (182.0).

The physician then determines a treatment plan, and in this case, a hysterectomy is performed. Following the hysterectomy, the pathologist examines the tissue to report histologic grade, tumor type, and depth of invasion of the specimen, Stainton says. The evaluation includes incidental tubes and ovaries, in which no pathology was found. This reflects the work involved in 88309 ( uterus, with or without tubes and ovaries, neoplastic).

Case 3: A 48-year-old woman presents with symptoms of abdominal pain and a sensation of fullness. She also reports irregular vaginal bleeding unrelated to her menstrual cycle (626.6). The physician performs a pelvic examination and finds an enlarged uterus. Ultrasound indicates presence of large fibroid tumors, and the patient is scheduled for a hysterectomy with the preoperative diagnosis of leiomyoma (218.x).

The pathologist receives the surgical specimen consisting of uterus and bilateral tubes and ovaries. Examination of the uterus confirms extensive leiomyoma of the distended uterus, and the service is reported as 88307 ( uterus, with or without tubes and ovaries, other than neoplastic/prolapse). Although the tubes and ovaries were removed as an adjunct to the uterus, the surgical note described an enlarged, cystic right ovary, requiring individual examination and diagnosis. The 6-cm ovary had not been palpable during the initial examination due to the displacement of the uterine fibroids. The pathologist evaluates the ovary and reports a diagnosis of serous cystadenoma (220), providing an additional surgical pathology service of 88307 ( ovary with or without tube, neoplastic).

Because the ovary represented a distinct, significant pathology from the uterus, reporting the additional surgical pathology code is appropriate. The ovary was a separate specimen based on the CPT definition, Yurco says. However, cases like this often require a judgment call, and you have to be very careful not to unbundle. For example, if an attached ovary shows only minor pathology, such as a few nests of endometrial tissue, it would not warrant reporting an additional service.

Stainton agrees. If the ovary requires individual examination and diagnosis because it shows a distinct pathology from the uterus, it represents a separate specimen and should be reported separately, he says.