Pathology/Lab Coding Alert

Capture individual specimens -- even if you received them en bloc

Don't let a fear of "unbundling" keep you from the payment you deserve for complex surgical pathology evaluations. Although CPT directs you to treat tissues that surgeons normally submit together as a single pathology specimen and code, that doesn't mean you should never individually report common tissue combinations -- such as kidney with attached ureter. Use the following pathology case to learn when and how to code for separate specimens.

Study This Surgical Pathology Report

Tissue Submitted:

Right kidney, ureter, urinary bladder cuff

Gross Description:

The tissue consists of a 250-gm kidney with attached perirenal fat, 24-cm segment of ureter, and portion of bladder cuff. The kidney measures 10 cm x 5 cm x 3 cm, with perirenal fat extending for 3 cm around the kidney. The ureter measures 0.3 to 1.1 cm in diameter.

About 7.5 cm from the bladder cuff, the ureter displays a fusiform swelling 3 cm long and ranging from 0.5 to 1.1 cm in diameter. The opened ureter reveals a light-tan papilliferous lesion and thickened ureteral wall. The remaining ureteral mucosa is tan, pink and smooth except for an area of granularity noted distal to the tumor. Cassettes A1 and A2 contain sections from this area within the inked tumor margins. Cassette A3 includes cross sections of the ureter distal margin, and cassette A4 contains random ureter sections distal to the mass. Cassette A5 includes random ureter sections proximal to the mass, with the hilar vessels sectioned in A6.

The kidney is bivalved. The mucosa of the renal pelvis has a slightly granular appearance although there are no discrete masses. The renal parenchyma also shows no masses. Cassettes A7 and A8 contain sections of renal pelvis, with other random kidney sections in cassettes A9 and A10.

Cassette A11 contains random sections of perirenal fat, which yielded no lymph nodes upon dissection.

Microscopic Description:

Sections of the mid-ureter tumor in cassettes A1 and A2 show a papillary transitional cell carcinoma (TCC) grade 2 of 4 with no invasion of the ureter walls. In situ carcinoma exists around the circumference of the ureter lumen. Inked external margins show no evidence of tumor.

The distal surgical margin (A3) is free of tumor involvement, although random distal ureter sections in A4 show additional foci of TCC.

Cassettes A5 and A6 show no abnormalities in proximal ureter sections or pelvic vessels respectively.

Renal pelvis sections (A7 and A8) show areas of focally thickened urothelium with some papillary-like projections above the surface and rounded nests of transitional cells within the lamina propria. Also note some nuclear atypia in the overlying epithelium and edema and inflammation within the lamina propria.

Kidney sections (A8 and A9) show chronic inflammation with some obsolescent glomerula.

Perirenal fat yields no lymph nodes and shows no tumor involvement (A11).

Diagnosis:

Right ureter and bladder cuff:
1. Papillary TCC, grade 2 of 4, involving mid-right ureter
2. Foci of TCC in situ of ureter
3. Distal surgical margins free of TCC involvement
4. No invasion of ureter wall
5. Inked surgical margins free of tumor involvement

Right Kidney:
1. Renal pelvis shows low-grade papillary TCC without invasion
2. Kidney sections show focal chronic inflammation

Does Your Coding Match the Experts'?

You should report two surgical pathology codes for this case because the pathologist examined two separate specimens, say experts Stephen Yurco III, MD, partner and pathologist at Clinical Pathology Associates in Austin, Texas; and Pamela Younes, MHS, HTL(ASCP), CPC, assistant professor at Baylor College of Medicine in Houston. Report the kidney as one specimen (88307, Level V -- Surgical pathology, gross and microscopic examination, kidney, partial/total nephrectomy) and the ureter examination as a separate service (88307, ... ureter, resection).

Why? A kidney specimen often includes an attached ureter section, so why does this case warrant reporting the ureter as a separate specimen?

Because: Specimen definition drives coding. CPT defines a specimen as "tissue or tissue(s) that is (are) submitted for individual and separate attention." Codes 88302-88309 specifically name 175 tissues that fit the specimen definition. To guide your code selection, you should consider the CPTspecimen list, as well as knowledge of what tissues surgeons normally submit together.

Although surgeons may often include a small portion of attached ureter with a kidney specimen, they do not usually submit the entire ureter. CPT lists both kidney and ureter resection as specimens.

"We typically receive only a small ureter section attached to a nephrectomy specimen," Yurco says. "The surgeon often doesn't remove the entire ureter when resecting a kidney for renal cell carcinoma, which is a far more common occurrence."

"This case is unusual because it includes the entire ureter, all the way down to the bladder cuff," Younes says. "Amore common kidney specimen received for renal disease may include a 4- to 5-cm ureter segment."

Don't Miss: Separate evaluation and diagnosis can overrule "same container."

CPT further defines a specimen as tissue(s) "requiring individual examination and pathologic diagnosis." Even if the surgeon submits en bloc tissue in a single container, you may sometimes need to separately code different specimens that the pathologist individually examines and diagnoses.

"This case involves a multi-focal cancer that required the pathologist to examine and diagnose a tumor in the ureter, and separately examine and diagnose the kidney," Younes says. Be aware, however, that based on CPT definition, some specimens cannot be separated, such as radical mastectomy with axillary lymph node dissection.

Protect yourself: Don't code what the report doesn't document.

Unless the pathology report documents separate examination and diagnosis of different specimens, you cannot report an individual code for each tissue. "The pathology report in this case documents examination of a mid-ureter tumor and margins, and also provides a diagnosis for that specimen," Yurco says. He points out that the report also documents examination and diagnosis of the kidney, which CPT lists as a separate specimen.

You could use bladder biopsy code 88305 (Level IV -- Surgical pathology, gross and microscopic examination, urinary bladder, biopsy) to describe a bladder cuff specimen under some circumstances, "But because the pathology report does not document the pathologist's examination or diagnosis of the bladder cuff, you should not separately report 88305 in this case," Younes says.