Pathology/Lab Coding Alert

Question: During a chart audit, we were told that a specific case did not support billing a calcification. The pathology report noted "gritty calcifications" in the gross description and stated that the "specimen will be allowed to decal prior to further processing." The pathologist used the term "calcified plaque" in the final diagnosis section of the report. Does this support billing +88311?

Arkansas Subscriber

Answer: Based on the information you provided, billing +88311 (Decalcification procedure (List separately in addition to code for surgical pathology examination)) along with the primary service code would be appropriate. That means your claim should list a code from the range 88302-88309 that describes the specimen the pathologist examined, such as 88305 (Level IV - Surgical pathology, gross and microscopic examination ... Bone exostosis ...) in addition to +88311.

If your documentation makes a clear statement that the specimen went through a decalcification procedure, billing +88311 is appropriate. Even something as simple as stating, "following decalcification, tissue submitted in one cassette ..." should suffice. The key word that must appear in the report is "decalcification" or some derivative such as "decalcify," "decalcified," or even "decal" should do.

The auditor may have felt that the statement "will be allowed to decal" did not provide evidence that the procedure was completed. Using a different verb tense to indicate that the lab personnel did decalcify the specimen might make the difference. Hopefully asking the auditor for clarification will give you a clue.