Pathology/Lab Coding Alert

Question: Please help with the ICD-10 coding on the following multiple specimens received in a prostatectomy case:

Specimen A) Urinary Bladder, Neck Margin, Bladder Neck #1
Specimen B) Urinary Bladder, Neck Margin, Bladder Neck #2
Specimen C) Urinary Bladder, Neck Margin, Bladder Neck #3
Specimen D) Lymph Node, Bilateral Pelvic Lymph Nodes
Specimen E) Prostate

The pathology report notes the following diagnoses:

A-C) Benign Fibromuscular Stroma with Chronic Inflammation; No evidence of Malignancy
D) Seven Lymph Nodes Examined, Zero Lymph Nodes involved by Carcinoma
E) Prostatic Adenocarcinoma, see synoptic report below

The pathologist reported C61 as the diagnosis code for the case. We’ve found in the past that we get Medicare denials for bladder neck biopsies that we report as 88305 if the diagnosis is C61. Please help.

Texas Subscriber

Answer: The purpose of assigning diagnosis code(s) is to “describe the patient’s diagnosis, symptom, complaint, or problem,” according to Centers for Medicare and Medicaid Services (CMS), so you’re not required to assign a different ICD-10 code to each specimen in the case. From that perspective, simply assigning C61 (Malignant neoplasm of prostate) is appropriate for this case, because prostate cancer is the problem diagnosis that requires treatment.

Caveat: If you have a situation in which the diagnosis doesn’t seem to support the CPT^® codes for the case, you may assign distinct diagnoses for each distinct specimen. Because you want to document separate bladder specimen(s) and distinct lymph nodes that are not bundled with the prostate specimen, you may want to assign distinct ICD-10 codes for each specimen.

Lymph nodes: Because these are “normal” tissue and show no pathology, you should assign the ordering diagnosis.

Bladder neck: You should be aware that a prostatectomy specimen generally includes any small portions of bladder neck that represent margins for the prostate resection, so it’s unlikely that this case warrants three units of 88305 (Level IV - Surgical pathology, gross and microscopic examination, Urinary bladder, biopsy) in addition to the prostatectomy (88309, Level VI - Surgical pathology, gross and microscopic examination, Prostate, radical resection). If the pathology report documents that these bladder neck margin specimens are separately submitted for individual examination and diagnosis, however, you would need to document a distinct diagnosis, such as N41.3 (Prostatocystitis).

You are correct that Medicare won’t support an 88305 charge for a prostate cancer diagnosis (C61), because Medicare requires you to report prostate biopsies as G0416 (Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method).