Pathology/Lab Coding Alert

Question: Our pathologist examined a colon resection for tumor and also examined two colon "donuts" generated by the anastomosis procedure from the proximal and distal ends of the resection. How should we code the procedure?

Florida Subscriber

Answer: Report the pathologist's examination of the colon resection as 88309 (Level VI -- Surgical pathology, gross and microscopic examination, colon, segmental resection for tumor).

How to code for the colon "donuts" is not as clear- cut. As you described, the surgical anastomosis often results in two separate pieces of colon tissue (cross-wise slices) from the proximal and distal ends of the resection. As such, these are the margins of the resection, even though they are separate pieces of tissue.

Experts have stated that you can separately report the donuts under certain conditions. For instance, in Pathology Service Coding Handbook version 8.2, Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc. in Simpsonville, Ky., states, "If the surgeon draws attention to the donut by mentioning it on the requisition, sending it to pathology in a separate container, etc., the donut is separately chargeable; or if colon surgery was undertaken for cancer or if significant pathology is found in the donut, it's separately chargeable."

Choose the code: As an unlisted specimen, you-ll have to assign the code that "most closely reflects the physician work involved when compared to other specimens in that code," according to CPT instruction. Padget suggests 88305 (Level IV -- Surgical pathology, gross and microscopic examination, colon, biopsy) if the work approximates the level of work involved in a colon biopsy, or 88304 (Level III -- Surgical pathology, gross and microscopic examination, colon, colostomy stoma) if the work is comparable to the colostomy stoma exam.

Caution: In CAP Today, January 2008, the College of American Pathologists asserts that you should not separately report colon donuts. Even acknowledging that the surgeon separately submits the donuts, CAP states, "If donuts are examined microscopically, they constitute the surgical margins of the - colon segment. Donuts should be considered along with the colon cancer specimen, which is given the CPT code 88309."

Food for thought: "Surgeons often submit a surgical margin for individual pathologic evaluation, separate from the main resection specimen," Padget says. "For example, partial breast mastectomy and Mohs skin surgery frequently yield one or more surgical margins as separate surgical specimens. CAP and other coding authorities recognize that you can separately charge for distinctly identified and diagnosed surgical margins in these instances, so it's puzzling why you might not also separately charge for a colon resection margin -- a so-called -donut- -- under comparable circumstances."

"Medical literature supports the notion that an anastomosis ring produced during colon surgery is not necessarily an inconsequential -throw away- tissue remnant," Padget says. "It can have predictive value for recurrence of dysplasia or ulcerative colitis, for example, or the pathologist may discover residual abnormal cells. The investigators in one study even went so far as to recommend that colon resection -donuts- be evaluated by a pathologist whenever the primary tumor is less than three centimeters from the distal resection margin.

"I believe that CAP swept with too broad of a brush when it suggested that you can never separately charge for colon resection -donuts- -- that you must always bill them as part of the main colon resection. I can find no clinical rationale or administrative precedence supporting that position; instead, treating an anastomosis ring as any other surgical margin appears to be most appropriate, as was described in the February 2001 issue of Pathology/Lab Coding Alert. In other words, if the surgeon separately identifies this tissue in some fashion and/or if the responsible pathologist has reason to believe the tissue has clinical significance for the patient, then it's separately chargeable," Padget says.