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I am curious about how others code for pathology. I have been in my position for several years, and this is my first coding job. I am interested in streamlining our process and being more efficient, and I would like to understand how others code for pathology.

Are you employed by the pathology office, or are you coding for a service that contracts with the pathology office?
Do you code using a particular software?
Does your office also bill or is that outsourced?
When you code, do you have access to the patient's electronic health record?

I am employed by and work in the office for an independent lab of 15 pathologists. We use PowerPath for reporting. I can access the pathology report in PowerPath, but I write the codes on a paper copy of the requisition which is then sent to an outsourced billing office. We work with a number of hospitals, surgery centers, and private physicians and do not have access to electronic health records. Any records needed are requested by fax or phone.

What does your coding job look like?
 
Sharing our process for pathology coding

Hi,
I was a brand new coder 2 years and 2 months ago when I took on pathology and laboratory for our facility. I am passionate, self taught, research & ask lots of questions pathology coder.

Are you employed by the pathology office, or are you coding for a service that contracts with the pathology office? I work for our region and work for another region when their pathology coder is on vacation. I also work the pathology denials for another region.

Do you code using a particular software? we use Epic

Does your office also bill or is that outsourced? We bill

When you code, do you have access to the patient's electronic health record? This answer would be sometimes. We receive specimens to process from other facilities. I am only able to access the requisition, not the operative report.

My pathology team that I work closely with drops the charges that they want to bill out their pathology charges. I review the pathology - make sure the appropriate codes have dropped - unfortunately mistakes do happen - a missed stain or decalcification or wrong Level dropped. I email my findings directly to the pathologist and after they have reviewed and approved to correct the charges, I make the necessary changes.

Like I said I have a great working relationship with all the different regions I work with. Have you had the "opportunity" to tour your pathology department - have someone walk you through and educate you on what procedures are done? I did that about 7 weeks after starting. I also had monthly meetings with my pathology director for a short time to make sure we were all on the same page.

I have questions all the time - and to this day still ask. Hopefully you have that relationship with your pathology team where you can ask.

If I missed anything, please feel free to ask.
From reading your responses for other coding questions I feel you are doing a great job! Continue on with your education/research and be successful.

Thanks,
Dana Chock, CPC, CCA, CANPC, CHONC, CPMA
Anesthesia, Pathology, and Laboratory coder
 
Thanks for your message and the encouragement.

How many pathologists are part of your service? When you say you have access to the requisitions, do you mean the paper copy or a scanned copy? If scanned, at what point in the process are the requisitions scanned? Our requisitions don't get scanned until they are sent out to the billing office, so I code directly on to the paper copy, not with software.

Our office is completely self-contained, meaning the lab is just down the hall from me, the pathologists have offices in the same area, and administration is here, too. So, I have ready access for questions, which has been great for learning. I asked for a laboratory tour early in my employment. It helps a lot to understand the coding if I know what has happened to the specimens!
 
Continuation - pathology coder

How many pathologists are part of your service? For Central I have three, for West region when I substitute I am guessing at around 5-6 pathologists, when working denials for East there are probably 7-9.

When you say you have access to the requisitions, do you mean the paper copy or a scanned copy? The scanned/copied order for the reason the specimen was submitted to our pathology department.

If scanned, at what point in the process are the requisitions scanned? No kidding in our organization (no disrespect to anyone watching my comments but....) it can take SEVERAL weeks. I defer charges WHEN I have to - until I see the requisition especially if sometimes if it isn't cut & dry or I get a "consistent with" - I will just have to wait to complete the coding.

Our requisitions don't get scanned until they are sent out to the billing office, so I code directly on to the paper copy, not with software.

Our office is completely self-contained, meaning the lab is just down the hall from me, the pathologists have offices in the same area, and administration is here, too. So, I have ready access for questions, which has been great for learning. I asked for a laboratory tour early in my employment. It helps a lot to understand the coding if I know what has happened to the specimens!
I really admire one of our Pathologists - she actually presented to one of our coding meetings earlier this year and it was amazing! She gave a "complete" tour to my entire group and had a "knock me out of this field presentation" that no one was expecting. I am actually being asked to get her to speak again this coming year.
I have worked from home since Oct 2012 - any issues I have I can call my team or email them for help unless I show up with baking treats... I am not afraid to defer a charge until it has been researched to death and all the "right" questions have been asked.

Like I said earlier, keep up the GREAT work, when I see you have responded to a request there is no need for me to because I usually agree with what you are stating and because I know you pretty much have it covered.

I would love to have expanded on the bone excision (from a previous/prior post) but I have been "swamped". I would love to chat with my team and see if they have anything to offer that is "black & white" on this topic and in writing hopefully???

Have a great evening!

Thanks,
Dana Chock
 
Thanks again for the information. Lucky you to work from home!

If you get time, I would be very interested to hear your opinion on the bone specimens!
 
wondering what CPT and ICD code you use for just the blood draw??
Can you give me some direction to find this information. New to labs, even though I have been billing and coding for 16 years.
Thank you
Sandi
 
Hi Sandi,

I would suggest you ask your question in a new message. It will get lost here. I don't code for those procedures, so I won't try to answer this. :eek:
 
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