Pathology/Lab Coding Alert

Don't get tripped up on stain name

Each time you choose between 88312 and 88313, you have to remember the reason the pathologist ordered the stain - to identify micro-organisms or to diagnose other conditions.

What's in a name? Although CPT Codes provides specific stain names as examples in the code definitions, you have to choose the proper code(s) based on the stain's use. "The stain name and specimen type have far less impact on your selection of 88312 or 88313 than knowing whether the pathologist uses the stain to evaluate cell morphology or to confirm infectious agents," says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., a pathology business-practices publishing company in Simpsonville, Ky.

Steer Clear of Common Stain Mistakes

Avoid pitfalls when you're reporting stains from one of the following groups:
 

 +88312 - Special stains (list separately in addition to code for primary service); Group I for microorganisms (e.g., Gridley, acid fast, methenamine silver), each
 

 +88313 - Special stains (list separately in addition to code for primary service); Group II, all other (e.g., iron, trichrome), except immunocytochemistry and
immunoperoxidase stains, each.

Follow these tips to overcome three common 88312/88313 coding snags:

Snag 1. Stain Cocktail Yields Two Interpretations

Labs often perform multiple individual stains on a single specimen and code separately for each one. But what should you do if the lab uses a "cocktail" of two stains mixed together?

Example: The lab mixes periodic acid-Schiff (PAS) and Alcian blue and uses this single reagent to stain esophageal biopsy specimens when medically indicated. The PAS stain can help detect and definitively identify organisms such as fungi. Pathologists use the Alcian blue stain to assess cellular distortions indicative of Barrett's esophagus, which is a chronic peptic ulcer of the esophagus.

If the pathologist examines a PAS/Alcian blue-stained biopsy for the presence of micro-organisms and to investigate Barrett's syndrome, report the professional component (modifier 26, Professional component) of both 88312 and 88313 for the "cocktail," just as you would if the pathologist examined slides stained separately with PAS and Alcian blue. "The physician work is fundamentally the same whether the stains are separate or mixed, and I think that's why the AMA OK'd reporting two codes in this instance," Padget says.

Sample report: Look at the following pathology report for an example of documentation that supports coding both stains:

Preoperative Diagnosis
Operative findings: 4 cm of columnar metaplasia; Barrett's esophagus; rule out fungal infection.

Specimens Submitted
Biopsy of esophagus.

Pathologic Diagnosis
Esophagus, biopsy: Focus of specialized intestinal metaplasia (Barrett's esophagus); negative for dysplasia and fungi.
Comment: There is active inflammation at the gastroesophageal junction. The PAS/Alcian blue stain is negative for fungi, but identifies metaplasia consistent with Barrett's esophagus.

Gross Description
Five delicate tan 0.2- to 0.3-cm pieces. Five pieces in one cassette.

Microscopic Description
The pathologic diagnosis incorporates and reflects the microscopic examination of the sections prepared for the specimen(s).

On the other hand: You can't always report both 88312 and 88313 for the PAS/Alcian blue stain: "If the pathologist only interprets the Alcian blue staining, making a diagnostic statement about Barrett's esophagus but not evaluating the PAS component for micro-organisms, you should only code 88313-26," Padget says. 

Watch for: Coding for the technical component of a "cocktail" stain like PAS/Alcian blue was less clear-cut in the past. Some experts have advised choosing only one code because the lab prepares slides from only one reagent.

But the debate appears to be settled once and for all by the AMA's CPT Information Services unit. "According to a written response I've received from the AMA regarding this question, labs can report both 88312 and 88313 - adding technical-component modifier TC when necessary - when they process a specimen using a PAS/Alcian blue stain cocktail," Padget says.

Tip: "The CPT codes for the lab's technical- component charge should match the CPT codes for the pathologist's professional charge. That includes reporting only one technical code if the pathologist only evaluates one of the reagent's properties and therefore reports only one stain code," Padget says.

Snag 2. Special Stain Is Not for Tissue Alone

Special stains 88312 and 88313 are add-on codes found in CPT's surgical pathology section. But labs might perform these stains on sources other than a surgical pathology specimen listed under 88302-88309 (Surgical pathology, gross and microscopic examination). That means you might be billing an add-on code without a specimen exam code, and that's been a problem for some payers in the past.

Don't miss: Cytology and bone marrow cases often yield legitimate 88312 and 88313 charges, even though they're not in the surgical pathology code "family." Pathologists might examine special stain slides from a fine needle aspiration (FNA) or a bone marrow aspiration, for example.

Parenthetical notes in CPT's hematology and cytopathology sections direct coders to the 88312 series for special stains of certain nontissue specimens. To further clarify proper use, CPT 2004 changed the 88312 and 88313 code definitions from List separately in addition to code for surgical pathology specimen, to List separately in addition to code for primary service. "This change clarified that you can list the stains in addition to any primary service, such as an FNA, not just in addition to a surgical pathology service," says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

Exception: Two examples show how you might use 88312 and 88313 with nonsurgical pathology specimens:

Example 1: The pathologist orders an acid-fast bacillus (AFB) stain on a lymph node FNA to evaluate mycobacterial involvement in possible granulomatous disease. Report the pathologist's examination of the FNA as 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report). For the additional AFB stain service, also report 88312 for the Group I stain for micro-organisms.

Example 2: A pathologist performs a bone marrow aspiration, evaluates the smears, and examines an iron stain for the diagnosis of iron-deficiency anemia. Report the bone marrow specimen acquisition as 38220 (Bone marrow; aspiration only) and the evaluation as 85097 (Bone marrow, smear interpretation). For the iron stain, also code 88313.

Snag 3. Stain's Purpose Contradicts Code Definition

Most special stains that pathologists order with tissue, cytology and bone marrow examinations have a single use: detect a "bug" or highlight a particular morphologic attribute of the cells. But a limited number of special stains are "dual use."

For instance: Pathologists most often order a trichrome stain to evaluate mucin or fibrin content, but sometimes they use the stain to detect parasites.

The trichrome stain's dual-use capability creates an interesting dilemma for coders - the descriptor for 88313 specifically names trichrome, but if the pathologist uses trichrome to rule out parasites in a particular instance, should you report 88312 or 88313? 

"When CPT cites a specific test within a code descriptor as an example of the code's use, it's just that - an example," Padget says. "CPT Information Services recently confirmed that you should report a trichrome stain for micro-organisms with 88312, despite the fact that the 88313 code descriptor includes trichrome as an example." In other words, always code based on a stain's actual use.