Pathology/Lab Coding Alert

Question: Our pathologist examined a bone marrow aspirate and reported “scant cellular spicules.” However, the report also stated “erythroid cells, too few in number to assess dysplasia; blasts markedly decreased, with evident vacuoles.” Should we report this service since so little cellular material was present to provide diagnostic information? If so, how should we code the case?

Tennessee Subscriber

Answer: As long as the specimen contains some material and the pathologist reviews the slide(s) for diagnostic findings and issues a report, you should code and bill for the service. That’s true even if the cellular material is not enough to indicate or rule out a specific disease process. You should bill the bone marrow aspiration exam as 85097 (Bone marrow, smear interpretation).

Caution: Your pathologist should carefully choose the wording of a report for a situation like you described. If the pathologist had simply stated “nondiagnostic,” or “insufficient cellular material for diagnosis,” you’d have a hard time justifying reporting the 85097 code. Even if a payer covered the service, you’re opening yourself up to trouble if an auditor ever sees the case.

Documentation tip: “Take words like ‘scant’ and ‘insufficient’ out of your pathology reports,” suggests R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark. “Even if you don’t have definitive diagnostic information, state what you observe when you evaluate a specimen, such as ‘dysplasia not identified in red cells present,’” he advises.