JGGBALLEN
Networker
Hello and thank you in advance for any support you can offer!
Hopefully, this will reach someone with extensive auditing experience, particularly within the specialty of Pathology or someone who codes for this specialty.
I am conducting a retrospective Pathology review/audit. As this specialty is new to me and to my colleagues in our compliance dept I would greatly appreciate anyone guidance please.
1. Are there any consult auditing policies/guidelines for specific verbiage, similar to E/M?
2. Provider billed 80500/dx 174.4
From my perspective and presuming there is not much else to review I feel CPT 80500 with dx 233.0 & 174.4 is more appropriate...please read below.
The authenticate path consult report that I am reviewing has
dates obtained/received/reported, path#, pt identifiers, req phy nme & institution w/addr, case id, # of slides.
Body of report indicates (I have replaced the actual number with the #)
"Breast, left, 1 o'clock, ultrasound guided core biopsy"
"invasive mammary carcinoma, scarff bloom richardson Score=#"
"(tubles=#, nuclei=#, mitosis=#)"
"ductal carcinoma in situ (DCIS), intermediate nuclear grade, solid and cribform subtype"
"no definitive lymphovascular invasion is identified"
"immunohistochemical stains were unavailable for review, however per report:
ER: #%, positive,
PR: #%, positive,
HER2: #, negative,
K167: #%
"Comments: Slides will be returned to XYZ Lab"
3. I am having a difficult time grasping what to audit. I am prob looking for more than there is so I just need validation or education.
4. Consult code 80500 and 80502. Understanding that 80502 requires review of pt's med record is/are there specific documentation guidelines that are needed to reflect this type of consult?
5. What needs to be said within the path report? I expect med nec is driving this such as result from exam suspicious or inconclusive and the chart review is necessary before determining to order or request order additional testing.
6. If so, what other info is required in the documentation?
7. Should it be all in the one report or do pathologist document a secondary report (ex: separate progress and procedure report)
8. Do the documents that the pathologist reviewed within the medical records need to be signed/ countersigned?
9. Does a consult, between surgeon & pathologist, occur prior to receiving specimens?
10. If so, is this a billable consult or is it included in consult when specimen received (sort of pre-op period)?
Lastly, the surgical path seems fairly routine (will use CPT as guide/reference). however, provider billed 88305, -26 L1 & L2 (received 2 formalin (is this considered wet) specimens) and L3 and L4 88312, -26.
11. 88312, -26...it indicates "special stain" do I need to see documentation of that "special stain" within the report?
12. I gather that even if Dr. XXX actually examined the specimen the hospital bills that TC and the provider the interpretation; hence -26 on Dr. XXX charge? Are there any instances that the pathologist whole is doing exam and interpret can bill for both components?
13. I thought I saw something, while researching, about interpret only codes, but now I can't located. Is that correct and can you direct me to the publication please?
Hopefully, this will reach someone with extensive auditing experience, particularly within the specialty of Pathology or someone who codes for this specialty.
I am conducting a retrospective Pathology review/audit. As this specialty is new to me and to my colleagues in our compliance dept I would greatly appreciate anyone guidance please.
1. Are there any consult auditing policies/guidelines for specific verbiage, similar to E/M?
2. Provider billed 80500/dx 174.4
From my perspective and presuming there is not much else to review I feel CPT 80500 with dx 233.0 & 174.4 is more appropriate...please read below.
The authenticate path consult report that I am reviewing has
dates obtained/received/reported, path#, pt identifiers, req phy nme & institution w/addr, case id, # of slides.
Body of report indicates (I have replaced the actual number with the #)
"Breast, left, 1 o'clock, ultrasound guided core biopsy"
"invasive mammary carcinoma, scarff bloom richardson Score=#"
"(tubles=#, nuclei=#, mitosis=#)"
"ductal carcinoma in situ (DCIS), intermediate nuclear grade, solid and cribform subtype"
"no definitive lymphovascular invasion is identified"
"immunohistochemical stains were unavailable for review, however per report:
ER: #%, positive,
PR: #%, positive,
HER2: #, negative,
K167: #%
"Comments: Slides will be returned to XYZ Lab"
3. I am having a difficult time grasping what to audit. I am prob looking for more than there is so I just need validation or education.
4. Consult code 80500 and 80502. Understanding that 80502 requires review of pt's med record is/are there specific documentation guidelines that are needed to reflect this type of consult?
5. What needs to be said within the path report? I expect med nec is driving this such as result from exam suspicious or inconclusive and the chart review is necessary before determining to order or request order additional testing.
6. If so, what other info is required in the documentation?
7. Should it be all in the one report or do pathologist document a secondary report (ex: separate progress and procedure report)
8. Do the documents that the pathologist reviewed within the medical records need to be signed/ countersigned?
9. Does a consult, between surgeon & pathologist, occur prior to receiving specimens?
10. If so, is this a billable consult or is it included in consult when specimen received (sort of pre-op period)?
Lastly, the surgical path seems fairly routine (will use CPT as guide/reference). however, provider billed 88305, -26 L1 & L2 (received 2 formalin (is this considered wet) specimens) and L3 and L4 88312, -26.
11. 88312, -26...it indicates "special stain" do I need to see documentation of that "special stain" within the report?
12. I gather that even if Dr. XXX actually examined the specimen the hospital bills that TC and the provider the interpretation; hence -26 on Dr. XXX charge? Are there any instances that the pathologist whole is doing exam and interpret can bill for both components?
13. I thought I saw something, while researching, about interpret only codes, but now I can't located. Is that correct and can you direct me to the publication please?