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. [...]