Pathology/Lab Coding Alert

The codes are new, but the coding principles remain the same. "Just as last year, fine needle aspiration (FNA) and bone marrow aspiration or biopsy involve multiple steps and are reported using separate codes for each procedure," explains R.M. Stainton, MD, president of Doctors' Anatomic Pathology in Jonesboro, Ark.
 
Depending on the services provided for a specific clinical situation, separate codes may also be reported for specimen collection and pathologic evaluation as well as adjunct procedures such as cell blocks and special stains. Coding is further complicated if different billing entities perform the technical and professional components of some of these services, requiring the use of modifiers.

Bone marrow aspiration involves removing a small amount of fluid (aspirated cells) from the bone marrow through a needle attached to a syringe. "Although the pathology code for this service was deleted in CPT Codes 2002 (85095), the pathologist should still report the service if he or she provides it, using the new code added to the surgery section (38220, Bone marrow aspiration)," Stainton says. The placement of the code in the surgery section does not mean that only a surgeon can report the procedure.
 
A pathologist examines and evaluates the specimen, whether or not he or she was the physician who removed the aspirate. The evaluation is reported with CPT 85097 (Bone marrow, smear interpretation). "If the pathologist collects and examines the specimen, 38220 and 85097 should be reported," Stainton says.
 
Code 85097 includes a technical and professional component. The technical component involves the preparation of smears by the cytotechnologist, while the professional portion of the service is the interpretation of the smears by the pathologist. If the entire service is carried out by the same billing entity, report 85097 without modifiers. For some payers, modifiers must be used if the laboratory and pathologist bill separately. For Medicare and some other payers, the lab reports 85097 with modifier -TC (Technical component), and the pathologist reports 85097 with modifier -26 (Professional component).
 
Full evaluation of the bone marrow aspirate often entails additional services, Stainton says. "After the smears are prepared, the remainder of the sample is often processed as a cell block." The pathologist's evaluation of the cell block would be reported as 88305 (Level IV- surgical pathology, gross and microscopic examination, cell block, any source) in addition to 85097.
 
Special stains represent an additional service that is commonly carried out for bone marrow aspirate and is separately reportable. "For example, myeloperoxidase or Sudan black B stains are often used in the evaluation of leukemia patients to provide improved cytologic detail," Stainton says. Report 88342 (Immunocytochemistry [including tissue immunoperoxidase], each antibody) for the stains in addition to codes for other services provided.

The bone marrow biopsy (BMB) procedure is similar to the aspiration except that the specimen is an intact tissue sample rather than fluid. The biopsy is carried out through a small incision with a needle or trocar inserted through the cortex of the bone to remove a small bone marrow tissue core. The pathologist may remove the biopsy specimen, or a hematologist/oncologist or surgeon might carry out the procedure. Prior to this year, taking a BMB specimen was reported with 85102 (Bone marrow biopsy, needle or trocar). However, this code was deleted in CPT 2002 and replaced by 38221 (Bone marrow biopsy, needle or trocar).
 
Similar to coding for bone marrow aspiration, the preparation and evaluation of the BMB is a separate service. "The BMB is a surgical pathology specimen, reported with 88305 (Level IV- surgical pathology, gross and microscopic examination bone marrow, biopsy)," Stainton says. The preparation and evaluation of the BMB  specimen also involves a technical and professional component. If the services are billed by separate entities, modifiers -TC and -26 can be used to indicate the portion of the service provided.
 
Preparation of BMB specimens for evaluation often requires an additional step to remove calcium, which is not a bundled service, Stainton says. Code 88311 (Decalcification procedure) should be reported in addition to 88305 in these cases.
 
Special stains are also often carried out for BMB specimens, and these are separately reportable, Stainton says. "For example, an iron stain might be carried out to aid in diagnosis of iron deficiency or sideroblastic anemia, and would be reported as add-on code 88313 (Special stains; Group II, all other, [e.g., iron, trichrome], except immunocytochemistry and immunoperoxidase stains, each)."
 
Note: If a BMB and aspiration are carried out through the same incision, only one service can be reported. For this reason, a Correct Coding Initiative (CCI) edit pro-hibits reporting 38220 and 38221 together for the same patient on the same day. However, if the biopsy and aspiration are from two different sites or two separate patient encounters, both services can be reported using modifier -59 (Distinct procedural service).

As with coding for bone marrow aspiration and biopsy, FNA can involve several steps that are separately reportable. Like the bone marrow sampling codes, FNA codes were changed in CPT 2002. "Coders need to be aware of all the components of FNA that a provider might perform, and which codes to use to capture each service provided," says Lena Spencer, MA, HTL (ASCP), HT, QIHC, a histotechnologist at Norton HealthCare in Louisville, Ky.
 
Two of the four codes were deleted in CPT 2002 88170 (Fine needle aspiration; superficial tissue [e.g., thyroid, breast, prostate]) and 88171 (... deep tissue under radiologic guidance). Similar to coding for bone marrow aspiration and biopsy, these were the codes that identified removing the specimen from the patient. Similar to the deleted bone marrow sampling codes, new codes for FNA specimen collection were added to the surgery section in CPT 2002:
 

10021 (... without imaging guidance) and
 

10022 (... with imaging guidance). Rather than indicating the tissue involved in the aspiration, the new codes are differentiated by whether imaging guidance is used to direct needle placement.
 
Both procedures involve inserting a long, slender needle into a suspicious lesion and aspirating fluid (cells) for evaluation. When the lesion is superficial, such as a suspicious breast lump, the physician is often able to place the needle and withdraw an adequate specimen without any imaging guidance. This service is reported with 10021. However, deep tissue lesions that cannot be viewed from outside the body, such as a lung lesion, often require radiological guidance. Any FNA that involves imaging guidance is reported with 10022.
 
The pathologist should only report 10021 or 10022 if he or she collects the specimen. "Our pathologists typically conduct superficial FNAs but have a radiologist perform those requiring imaging guidance," Spencer says. However, if the pathologist aspirates a deep lesion while the radiologist provides imaging supervision, only one physician can report the FNA service. In such cases, the pathologist would report the service (10022), and the radiologist would report a different code for radiological supervision and interpretation as directed by the note following 10022 in CPT 2002. These codes are 76003 (Fluoroscopic guidance for needle placement ), 76360 (Computerized axial tomographic guidance for needle biopsy ) and 76942 (Ultrasonic guidance for needle placement ), depending on the imaging guidance given.
 
Codes 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]) and 88173 (...  interpretation and report) are used to report the evaluation of the FNA specimen. "They should be reported by the pathologist who performs the evaluation whether that same pathologist collected the FNA sample and reported 10021 or 10022 or not," Spencer says.
 
Although 88172 and 88173 describe FNA evaluation, they represent different services and, in fact, both are often performed for the same patient and reported together,  Spencer says. A pathologist reports 88172 to describe the immediate microscopic examination of the aspirate to ensure the presence of diagnostic material. The patient remains prepped while the pathologist evaluates the FNA for adequacy so that more aspirate can be immediately obtained if necessary. If a second aspiration is performed because the first specimen proved inadequate, 10021 or 10022 should be reported again.
 
Once an adequate specimen is available, the cytologist will prepare smears, and the pathologist will evaluate, interpret and report on the FNA. This service results in a diagnosis made by the pathologist and is reported as 88173.  
 
Cytology specimens obtained through FNA may be processed with special stains and are separately reportable, as they are for bone marrow specimens. "For example, an acid-fast bacillus (AFB) stain may be carried out on an FNA specimen from a lymph node with suspected granulomatous disease," Spencer says. Report 88312 (Special stains [list separately in addition to code for surgical pathology examination]; Group I for microorganisms [e.g., Gridley, acid fast, methenamine silver], each) for the AFB stain.
 
"Immunoperoxidase stains are also frequently used for FNA specimens to differentiate cancer types," Spencer adds. "For example, a prostate FNA may be processed with a high-molecular-weight cytokeratin stain, or a breast FNA with ER/PR (estrogen/progesterone) stain." Each of these stains would be reported as 88342 (Immunocytochemistry [including tissue immunoperoxidase], each antibody).

"The key to fair payment for FNA or bone marrow biopsy or aspiration is to report each procedure that is provided from sample collection to lab processing to examination and interpretation," Stainton says.