Surgical Pathology Coder

Surgical Pathology Evaluation and Management (E&M)

2011-07-13T08:12:00.000-07:00

There is no reason a surgical pathologist cannot see a patient in the office setting to perform an evaluation and management (E&M) service (99211 - 99215). This rarely occurs, but as licensed physicians, they are capable of evaluating a patient, rendering a diagnosis, and prescribing a treatment plan.

In fact, this is what surgical pathologists do all the time, they just do not see the patient in person. Rather, they examine and diagnose a portion of the patient. To a pathologist, the equivalent of E&M codes are the surgical pathology codes they use to describe specimens, in average levels of expected complexity.

When a pathologist renders a diagnosis on a surgical specimen, he or she is rendering a diagnosis for the patient. The tissue is diagnosed, and, because the tissue belongs to the patient, the diagnosis belongs to the patient. Whether systemic signs and symptoms are visible, the pathological diagnosis still applies to the patient.

When a surgical pathologist, or a heme pathologist, recommends further clinical correlation, they are recommending a further consideration for the patient's care plan. They are not equivocating on the diagnosis they have supplied for the patient.

Unlisted specimen: Heart

2011-06-28T08:11:00.000-07:00

While many laboratories may not see entire hearts being submitted as surgical pathology specimens, there are places that do get them on a fairly regular basis. An entire heart is an unlisted specimen in CPT. Even if your lab will never receive a heart, the same notions apply to assigning a CPT code to a heart, as would be the case with any other unlisted specimen.

While CPT does have a comprehensive list of 225 possible specimens, I've got an additional forty or so that I've come across over the years, that are not listed in CPT. Knowing how to think of these odd tissues leads to appropriate coding.

I extended the subscription date last month by another five days, and that seemed to work well for people who needed time to think it over. The same deal will apply for July. While the latest issue comes out on the first of every month, it is not reissued. People signing up for a 6-month subscription by July 5, will receive July through December issues. People subscribing after July 5, will receive subscriptions beginning August 1.

Subscribe today!

Subscription offer

2011-05-30T13:56:00.000-07:00

Ever wonder the difference between a simple excision and an extensive resection? The precise meaning and rationale behind all the different prostate specimens? Prostate TUR? Prostate Biopsy? Prostate, radical resection? Prostate, other than radical resection? 88305, 88309, or 88307?

The Surgical Pathology Coding Newsletter describes one surgical pathology specimen each month, in depth. Subscribe for six months of the newsletter for a very reasonable $25.00. Subscriptions received prior to June 5, 2011 will be sent out as a pdf document (this is an electronic newsletter only at the moment) on June 6. Subscriptions received after June 5, will begin on July 1st, 2011. The June issue deals with Thyroid, total/lobe (88307), lymph nodes, parathyroid glands, margins, and other issues. It can be both more complicated and simpler than many people think.

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Parathyroid gland in a thyroid lobe - bundle?

2011-05-13T13:20:00.000-07:00

Intra-parenchymal parathyroid glands are incidental to a thyroid resection, and they are not unbundled for independent code assignment.

Discovering an intra-parenchymal parathyroid will not influence the patient's care plan. For that reason, it is considered an incidental finding that does not merit assigning it its own code for an independent, medically necessary examination and diagnosis. When a total thyroid or thyroid lobe resection is received by a pathology lab, all of the related activity and findings are contained in the code Thyroid, total/lobe (88307) in CPT.

This and other issues dealing with thyroid resections in the surgical pathology setting will be discussed in the next issue of The Surgical Pathology Coding Newsletter that comes out on June 1, 2011. The newsletter is emailed to subscribers on the first of each month as a PDF document. Subscriptions cost $25.00 for six months. Readership is growing. Don't be left behind.

Surgical Pathology - unit of service

2011-04-05T23:28:00.000-07:00

CPT is very clear that the unit of service is the specimen. The specimen is whatever the clinician submits to the lab for individual examination and diagnosis.

In the case of finger or toe amputations (88302 or 88305 depending on whether trauma was involved or not), the unit of service is not the number of fingers or toes, but the number submitted for individual examination and diagnosis. Let's just stick with two fingers removed for trauma, shall we?

A container is submitted with a requisition that identifies the specimen as "Two fingers." This is one specimen because the surgeon is requesting a single exam and diagnosis (88302 x1). If the requisition reads, "Ring and middle finger," and no indication is made which is which, this is still a single unit of service (88302 x1). Two fingers, one exam and one diagnosis.

A container is submitted with a requisition that states, "Ring and middle finger, stitch on ring finger." This indicates that the surgeon is requesting an individual exam and diagnosis for the finger with the stitch, and another for the finger without a stitch. By differentiating between them, he or she is identifying them as unique specimens. Two examinations, two diagnoses, two units of service (88302 x2).

Two containers are submitted. One is labeled, "Ring finger," and the other is labeled, "Middle finger," on the requisitions. This is treated like any other specimens received in two containers. The request for two individual examinations and diagnoses is explicit and the codes reported should reflect this (88302 x2)

CPT defines 88302 as Fingers/toes, amputation, traumatic. This may seem to indicate that separately submitted fingers and toes need to be bundled together. This notion contradicts the definition of a specimen in the prologue that CPT uses to introduce surgical pathology codes. The unit of service is tissue or tissues submitted for unique and independent examination and diagnosis. The inclusion of plurals is meant to prevent unbundling when more than one digit is submitted for a single consideration by the pathologist.

As usual, the latest Surgical Pathology Coding Newsletter, will be available on the 1st of next month. Subscription rates are very reasonable and articles are very informative. A different specimen every month.

Unlisted specimen: Spinal cord biopsy

2011-03-29T09:13:00.000-07:00

Spinal cord tissue is not listed in CPT.

The spinal cord is a part of the central nervous system. While spinal cord tissue is not identical to brain tissue, it bears enough functional similarities for it to be considered the equivalent of brain tissue for coding purposes.

Spinal nerves occur outside the spine before they branch off throughout the body. Considering the cord the equivalent of a peripheral nerve ignores its role in the central nervous system. The cord, like the brain, is encased in bone and protected by meninges. Any removal of spinal cord tissue is an uncommon and delicate procedure that is not undertaken lightly. Spinal cord conditions and complications have the potential for more wide-ranging consequences than conditions that occur outside the spinal canal.

As always, The Surgical Pathology Coding Newsletter is available in which these topics are discussed in depth. Each monthly issue is dedicated to one specimen type with a thoroughness that isn't found in other pathology coding references. Subscriptions are $25.00 for six months, emailed out the first of every month.

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Level V gross exam does not exist (88300)

2011-03-14T21:26:00.000-07:00

For those people who are searching for the answer to the question if there can be surgical pathology Level V exam that is only examined grossly, the answer is NO. A Level I specimen (88300) requires a gross-only exam no matter what tissue is involved. Level II through Level V specimens have specific definitions but they require both gross and microscopic examination in order to render a comprehensive and medically necessary diagnosis. A fetus with dissection without a microscopic examination is still a Level I specimen. CPT doesn't qualify how many slides need to be prepared and examined to code higher than a Level I but if a microscope is not required to diagnose the tissue submitted, there is no other code that accurately describes the level of service beyond 88300. CPT is clear on that count.

To subscribe to The Surgical Pathology Newsletter, please read the last post or visit www.whaleheadking.com to learn about a reliable, accurate resource that describes surgical pathology specimen coding in terms that leave nothing to the imagination and false interpretations. At $25.00 for a six month subscription you will risk little money to gain plenty of understanding on how surgical pathology coding and billing works and be compliant without worries of overstepping the bounds of sound practice.

Our hundreds of readers cannot be wrong.

Unbundling a bursa or synovial cyst (88304)

2011-03-10T08:23:00.000-08:00

A bursa or synovial cyst that is part of a joint resection specimen should not be unbundled from the joint resection unless the cyst is separately submitted for independent examination and diagnosis. A cyst found within a larger joint resection should be considered incidental or an integral component to the joint resection itself.

...An excerpt from The Surgical Pathology Coding Newsletter dealing with Bursa/synovial cyst (88304). A six-month subscription to The Newsletter is available for $25.00. It will be delivered by e-mail the first day of every month.

Subscribe now or read more here. A new resource for surgical pathology coders.

Surgical Pathology Coding Newsletter

2011-03-07T12:44:00.000-08:00

Traffic on this blog has been exceeding my expectations. As a surgical pathology coder, I know there are few of us who deal with these issues on a daily basis. I also know there are not many resources out there for people looking for answers. I've used this blog to address some of the issues that cross my path as a consultant and I'm glad that some people have found it useful.

As I mentioned a few months ago, I am working on a definitive manual to describe surgical pathology coding as it applies in the field. As you can tell from this blog, I feel that an in-depth examination of the material is more useful than just quoting a few snippets of vague regulations that raise as many questions as they answer. I have spent many years coding pathology specimens, talking with pathologists, and dealing with payers and auditors. I believe in a solid foundation in the theory and practice of pathology coding.

While work on my manual is going well, I thought I would offer its contents on a monthly basis as The Surgical Pathology Coding Newsletter. This will be an e-mail document delivered on the first day of every month beginning on April 1, 2011. A subscription will cost $25.00 for six months. This is a reasonable investment for people who have no other resource to which to turn. Unlike other "Lab and Pathology" newsletters, this will only deal with surgical pathology specimens. I've subscribed to other newsletters for a lot more money and found that, month after month, they contain little that is useful for a surgical pathology coder.

The focus of most newsletters is on clinical laboratory rather than surgical pathology. This is understandable since most CMS regulations concern clinical lab tests. I see a need for a source of information that assists those who examine and diagnose tissue and the coders who translate those services into standard code. Based on the traffic here, I am not alone in thinking there is a vacuum for surgical pathology coding information on the market.

Each month I will discuss a specific specimen that is defined in CPT. I will interpret it literally and explore the various issues I have encountered in the field. Interpreting reports correctly with a solid understanding of the foundation of the coding system and how it is designed to work is essential for correct reimbursement for provided services. If you are looking to increase your understanding of surgical pathology coding The Surgical Pathology Coding Newsletter will be for you. Again, subscriptions are $25.00 for six months.

You can sign up now.....

Unbundling bone fragments (88304)

2011-02-22T08:20:00.000-08:00

The two most popular searches on this blog are excision vs. resection and unbundling issues. No surprise really. These are two things I've debated on more than one occasion over the years. Today, we'll discuss Bone fragment(s), other than pathologic fracture (88304).

Bone fragments are not normally unbundled from a larger, compound specimen if the findings are incidental to the condition affecting the whole specimen. While the presence of bone fragments is noteworthy and should be documented in a pathology report, their presence and condition is typically known to the surgeon on submission. If the surgeon specifies that he or she would like an independent accounting of bone fragments found within a specimen, this would justify a separately reported examination and diagnosis that will be assigned the appropriate code.

CPT distinguishes between bone submitted to confirm pathology other than pathologic fracture (88304) and bone submitted to rule out a suspected disease process or diagnose an unknown condition. The latter is more accurately described as Bone, biopsy (88307). Consider the difference well when assigning a code.

There is no official guideline to prevent anyone from unbundling bone fragments whenever the opportunity arises. That said, if the patient's prognosis and care plan are not advanced or affected by the diagnosis of incidental findings, they shouldn't really be considered "medically necessary." Medical necessity is, after all, the yardstick we use to justify coding and billing services. If it isn't in the service of patient care, an examination should not be unbundled from a larger specimen for billing purposes.

Nerve (88302)

2011-02-17T07:46:00.000-08:00

CPT differentiates between two types of nerve specimens. A nerve that is submitted for examination and diagnosis to confirm identification and the absence of disease is correctly coded 88302. The surgeon in these cases does not expect of any significant findings but, rather, is interested in verifying that a portion of nerve was removed during surgery. These specimens are not submitted to rule in or rule out any particular condition or suspected pathology.

If the request is to identify or confirm the presence of a particular nerve, 88302 is the code that most accurately describes the examination and diagnosis involved. If more extensive diagnostic information is requested, the CPT-designated descriptor Nerve, biopsy (88305) will more accurately describe the tissue at hand.

Hand/foot, amputation, non-traumatic: unlisted specimen?

2011-01-25T07:35:00.000-08:00

CPT designates codes for finger and toe amputations and for extremity amputations, but not for a hand or foot. Adhering to our usual literal definition of CPT's terms, an extremity can logically be considered to begin where the fingers or toes end. Since size is not a consideration when assigning codes, a hand or foot that has been amputated for any reason other than trauma should not really be thought of as an unlisted specimen, but as the CPT-designated Extremity, amputation, non-traumatic (88307).

Anyone insisting on referring to a traumatic hand or foot amputation as an unlisted specimen, can utilize the methodology applied to unlisted specimens and the result will be the same. Unlisted specimens that closely resemble their CPT-designated corollaries are most accurately described by the code that describes that corollary. In the case of a hand or foot amputated due to trauma, the CPT-designated specimen it most resembles is Extremity, amputation, non-traumatic (88307). The intellectual effort involved in the diagnosis of a hand or foot amputated for reasons other than trauma most closely reflects the physician work diagnosing a Level IV specimen.

How is it I can unequivocally state that a hand is equivalent to a whole extremity but not to five fingers submitted in the same container? Because a hand amputation contains the fingers and more. As long as there is more than fingers involved, the specimen can only be described as something other than a finger amputation. This fits in with the reasoning described in the first paragraph of this article.

The basics of bundling and unbundling pathology specimens

2011-01-20T07:40:00.000-08:00

The unit of service in Surgical Pathology is the specimen. This is usually considered to mean that whatever is separately submitted is assigned its own individual code. While this is usually a reliable guideline, there are instances when two separately received containers contain what is best described by a single code. Alternatively, there are cases in which one container may hold various distinct types of tissue requiring individual diagnosis and these are best described by more than one code.

The introduction to the Surgical Pathology section of CPT states, “A specimen is defined as tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathological diagnosis.”

Combining specimens into one overall code is known as bundling. Breaking out specimens to assign each its own code is known as unbundling. Neither should be done without careful consideration of the issues involved to ensure that appropriate codes are assigned to describe the specimens being examined and diagnosed.

Because bundling and unbundling can misrepresent the number of tissues submitted for separate attention, reports should clearly support the number of codes being reported. The appropriate bundling and unbundling of tissues into single or multiple codes is neither illegal nor unethical. The goal of coding and billing compliance is to report the medically necessary services performed on the patient’s behalf as accurately as possible in universally accepted code. If there are gray areas in interpretation, it is because no two cases are identical. The documentation must support the number of codes being assigned according to the standards supported in CPT. When this principal is adhered to, there can be no question that bundling or unbundling was done appropriately.

Soft tissue biopsy - 88305?

2011-01-14T05:14:00.000-08:00

Questions about soft tissue biopsy vs soft tissue excision seem to be what bring most people here. Let me try to address the soft tissue biopsy issue again.

While the words “soft tissue biopsy” are used in reports and in conversation to describe a specimen, CPT does not recognize the term. In CPT’s terms, soft tissue can is considered to be either a debridement, a lipoma, a mass, an extensive tumor resection, or other than these things.

Soft tissue biopsies are commonly considered to be a Level IV specimen consistent with Soft tissue, other than tumor/mass/lipoma/debridement (88305). This is usually true but thinking of Level IV undifferentiated soft tissue as a biopsy rather than as being other than what it is not can cause confusion. After all, a biopsy of a soft tissue mass is also a soft tissue biopsy but it is not a Level IV specimen. A biopsy of debrided soft tissue is also a soft tissue biopsy but it is not a Level IV specimen.

CPT contains descriptions for numerous biopsies but soft tissue is not one of them. If the soft tissue being submitted for examination and diagnosis is other than a tumor, a mass, a lipoma, or a debridement, it is correctly coded 88305. Not because it is a biopsy but because it meets none of the other available definitions.

Prostate needle biopsy (88305)

2011-01-04T02:00:00.001-08:00

In 2009 the Center for Medicare and Medicaid Services (CMS) initiated a new code series to describe a certain type of prostate biopsy. These codes did not supersede the surgical pathology CPT code 88305 to describe Prostate, biopsy. Instead, they are intended to describe a specific technique that, if CPT were used literally, would generate a rather hefty bill.

Consider this an example of CMS interpreting CPT as we do here, without imagination or fudging to make the codes fit the specimen or deviate from the established guidelines.

G0416 is Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 1-20 specimens. The next codes in the series contain the same designation with the exception of the number of specimens involved. G0417 describes 21-40 specimens, G0418 describes 41-60 specimens, and G0419 describes greater than 60 specimens.

Needle saturation biopsy is a technique that maps out the prostate by taking many samples and submitting them to the lab for pathologic diagnosis. Receiving 40-80 core samples is typical and these samples are individually submitted because their exact location has to be known in order to paint an detailed picture of the prostate's health. Under CPT, each separately submitted specimen would be assigned its own code (88305) resulting in a bill with as many charges as there are specimens received.

There is nothing wrong with this, but it cause a number of claims being flagged as "medically unlikely." There is no reason a patient cannot have 60 or more biopsies during an encounter (dermatology comes to mind) but these are the exception rather than the norm. In order to clarify what was being described, CMS opted for a set of codes more descriptive than what CPT allows.

This is really the reason why Level II HCPCS codes exist, to pinpoint and accurately report data of interest to CMS. When the guidelines governing the use of CPT codes were producing results that seemed unlikely, CMS did not argue that for this particular procedure, 60 specimens would be bundled together into a Level VI specimen. CMS invented a new series of codes rather than disrupt the balance already established in the Surgical Pathology section of CPT.

Another unlisted specimen: Tooth

2010-12-16T13:26:00.000-08:00

Teeth that are submitted to the Pathology Department usually undergo no more than a gross examination for identification and diagnosis. These will always be assigned the code for a Level I specimen, 88300. A tooth may occasionally be medically necessary to examine microscopically. This is a truly unlisted specimen.

Because a tooth must undergo decalcification prior to being examined microscopically, it is tempting to consider this specimen akin to bone, i.e. a tooth biopsy is equivalent to a bone biopsy. While this may seem a satisfactory solution, most pathologists would consider this a exaggeration of the diagnosis’ importance. Bone is a supporting structure that is entirely surrounded by soft tissue and the processes that occur within the marrow are vital to the body’s proper function.

As an anatomic feature that is relatively self contained and generally contains pathology of limited impact on the rest of the body, extraction of a tooth can be compared to a minor amputation. It is safe to conclude that a tooth that is submitted for microscopic examination and diagnosis has been removed for other than trauma.

Using the amputation example as a guide, an extracted tooth that is examined microscopically most closely parallels Fingers/toes, amputation, non-traumatic (88305). This does not, however, provide a wholly satisfactory conceptual comparison.

Using bone as the standard, then, it may be more satisfying to compare an extracted tooth that is submitted for microscopic evaluation to the CPT-designated Bone, exostosis (88305). While an exostosis is not an anatomic feature in its own right, the intellectual labor involved in diagnosing an exostosis is similar to that usually expended in diagnosing a tooth microscopically. Because microscopic examination of a tooth is above and beyond what is normally requested for this specimen, it should be considered more than bone fragments submitted incidental to an orthopedic procedure. For this reason, Bone, fragment(s), (88304) is not considered an apt comparison.

Unlisted specimens that closely resemble their CPT-designated corollaries are most accurately described by the code that describes that corollary. In the case of a tooth, the CPT-designated specimens it most resembles are both assigned 88305. The intellectual effort involved in the microscopic diagnosis of a tooth tissue most closely reflects the physician work diagnosing a Level IV specimen.

Coding a pericardium resection

2010-11-29T10:34:00.000-08:00

The pericardium is not explicitly listed in CPT. Like many other things, it's there if a coder sticks to the fundamentals of literal interpretation of CPT's designated specimens. There is an inclination among some people in our field to invent "unlisted" specimens. CPT allows for this in the introduction to surgical pathology coding but with very few exceptions, I find there is little need for this.

Pericardium is not as a CPT-designated specimen in its own right but it is soft tissue.

A biopsy of pericardium without any visible pathologic abnormalities should be coded the same as Soft tissue, other than tumor/mass/lipoma/debridement (88305). A mass or tumor arising from the pericardium should be assigned a code depending on whether it meets the criteria for Soft tissue mass (except lipoma), biopsy/simple excision (88307) or Soft tissue tumor, extensive resection (88309).

Someone is bound to ask: What about a pericardium resection? If there is no tumor, no mass, no lipoma, and it isn't a debridement, it is most accurately described as a Level IV specimen, 88305. To invent a special, "unlisted" pericardium resection specimen that carries a different code strikes me as disingenuous.

ICD-10 update

2010-11-25T02:20:00.000-08:00

I tend to deal with Common Procedural Terminology (CPT) here, but it is worth noting that ICD-10-CM and ICD-10-PCS are going to transform the coding field in the United States sooner than we expect. I was excited about ICD-10 initially but a review showed that, at least for diagnostic coding, not much is going to change. The structure and rationale is essentially the same and not much new ground is being broken there.

I don't do much procedural ICD-9 coding but the shift to ICD-10 is going to be more profound and complicated. It's not anything a thinking person can't master in a day. No paradigm shift, just more digits.

That said, CMS has released the following (MLN Matters # SE1033):

-The last regular annual update to both ICD-9 and ICD-10 code sets will be made on October 1, 2011.

-On October 1, 2012, there will be only limited code updates to both ICD-9 and ICD-10 code sets to capture new technology and new diseases.

-On October 1, 2013, there will be only limited code updates to ICD-10 code sets to capture new technology and diagnoes. There will be no updates to ICD-9-CM on OCtober 1, 2013 as the system will no longer be standard.

I was talking to someone this week about ICD-10 and she said, "Hasn't that been pushed back again?" No. It hasn't. It is a fact that ICD-10 will be the system we use in the autumn of 2013. It's nothing to get agitated about, more an opportunity to put the coder's viewpoint to the forefront and reinforce the fact that what we do for a living is important to keep the system running. Change, and this isn't really a big change, is something to be welcomed as we hone our skills and provide added value. The only ones who don't change are dinosaurs. I admit I use my books more than I use a 3M encoder and I come up with good and more thorough results as compatriots trained to trust the computer's intuition over their own expertise. I'm old fashioned but I welcome this change. Who doesn't want the opportunity to be more accurate?

The future is closer than you think.

Gross exam. Failed specimen (88300)

2010-11-13T14:03:00.000-08:00

Let’s say you get a specimen that someone in the surgical pathology lab grossly examines and then the tissue doesn’t survive processing. Does this deserve to be assigned a code and reimbursement?

Something is received with a requisition. It is examined and determined to be scant or negligible. “Small fragments suspended in formalin.” “Tissue may not survive processing.” “Possible fragments of _____ on gross exam.” If the final diagnosis is “tissue did not survive processing, gross exam only” there is nothing to translate into code. A surgical pathology examination, whether gross or microscopic, positive or negative, should contain a definitive determination of what is on hand. That it was skimpy or unsuccessful is nobody’s business but the pathologist’s and the clinician’s.

These are the kinds of specimens pathologists loathe because there is no reimbursement in them. They may be processed and examined but no diagnosis can be rendered. When all is said and done, the patient’s treatment plan isn’t furthered except that a repeat biopsy is recommended because nothing else can be said except that a basically empty container was received from the referring clinician.

What’s the reported diagnosis? “Tissue did not survive processing.” This doesn’t diagnose the patient’s condition so much as it describes what what submitted. It isn’t even identification of tissue. “Gross exam only.” So what? No diagnosis equals no code.

88300 is used to describe, in code, a gross examination that renders a diagnosis of the patient’s condition. If a pathologist has nothing to diagnose, there can be no code. Even “tissue received” means nothing in the scheme of a patient’s treatment plan. The concept of medical necessity requires that information be communicated that is of value to the patient’s treatment. Nothing added means nothing gained and nothing should be coded if it has no medical value.

Gross exams have their place. “Products of conception” is the most obvious example. So are the measurement, quantification and qualification of kidney stones. In these instances there is a confirmation that whatever was submitted is what it is and a part of a patient’s body. Examining formalin and confirming that, doesn’t qualify. Saying a biopsy is naught tells more of the procedure than the patient.

An unsuccessful removal of tissue that yields no workable specimen is of no value to anyone except the surgeon as an indication that he or she may need to work on his or her technique. An insurer or patient is justified in not wanting to pay that bill. There is no code for an empty container or a container filled with formalin. Processing this is either the cost of doing business for a pathology laboratory (hopefully infrequently) or an opportunity to bill the surgeon directly if it happens often enough.

Do not bill for a gross exam if there is no diagnosis. This is not what 88300 is intended to describe. CPT codes are for medically necessary services. If it doesn’t benefit the patient, it isn’t medically necessary. Just ask the Center for Medicare and Medicaid Services (CMS). The regulators take a dim view of padding the bills to cover expenses.

Insect gross exam (88300)

2010-11-01T10:24:00.000-07:00

Every specimen that is diagnosed after only a gross examination is a correctly coded 88300. For coding purposes, microscopic examination refers to the cutting of a specimen into thin sections for mounting on slides. It does not refer to an examination that can be performed as easily with a magnifying glass. An insect would not normally be coded as anything other than a specimen diagnosed grossly.

Examining the insect’s tissues for diagnosis is more properly the task of an entomologist rather than a surgical pathologist. Whatever insights may be gained from microscopic diagnosis of the insect’s pathology should be considered incidental to the human patient’s condition if undertaken at all in the Surgical Pathology lab.

Beyond the gross description of the specimen’s physical attributes, diagnosis should include the species of the insect. Describing an insect as “insect” or “tick” without other identifying information has limited medical value and does not require a referral for the professional services of a pathologist.

A book about surgical pathology coding

2010-10-30T15:31:00.000-07:00

How much demand is there for a hard copy book on surgical pathology specimens as defined by CPT? If there was ever a niche field in the medical billing/medical coding community, this is it. Is there any demand for such a product? How many surgical pathology practices are there in the US?

It just so happens that I have a draft in the works. It goes code by code, defined specimen by defined specimen and includes specimens undefined by CPT though, in writing this manuscript and absorbing the logic of CPT, I find there are few specimens that really qualify as "undefined."

I've read everything available on surgical pathology coding. Some of it I've applied. Other things seem to be excuses for up-coding and capturing as much revenue as possible based on the work involved. I stay away from those interpretations. While I appreciate why some people might want some wiggle room, I believe coding is designed to nail down a definition in five sequential digits that leaves little leeway for poetry.

CPT isn't concerned with the work involved or the expense incurred to render a diagnosis. Coding is different from billing no matter how much the two are intertwined. Sometimes you make money, sometimes you spend money without being compensated. That is good medicine. The more I look at the spread of accounts receivable, the more I am convinced that, if services are coded consistently and correctly according to a literal interpretation of CPT, a surgical pathology lab cannot help but be in the black.

It is an imperfect system but it works. It works fairly well. Trying to tie dollar amounts to particular specimens is a noble endeavor but it is one that betrays the intent of CPT. CPT only asks that a pathologist report the specimen. By using that as a guide there cannot be anything but profit without legal worries ahead.

I am not advocating anything illegal or disreputable or non-compliant with federal regulation or private contractual obligations. All I do is read CPT literally and apply codes to specimens to describe them as accurately as they can be defined. If this would be of interest to surgical pathology billers and pathologists and practice managers, I think a manual would be a marketable product. I have spent more time thinking about these things and binding them into a coherent and workable system than any in-the-field coder I've had the pleasure of knowing. I understand the nuts and bolts of the billing process but I also dwell in a realm of pure theory that can justify why codes are being applied and the expected reimbursement that follows.

88309 can feel right for a cancerous appendix but it isn't right. Eyeballing a stomach resection for volume reduction would seem to be 88304, but that isn't correct either. It is a stomach resection for reason other than for tumor: 88307. A vulvectomy may consist mostly of skin. It is still 88309. A melanoma removed from a patient's back requires fifty slides be mounted, stained and examined cell by cell. It is still Skin, other than cyst/tag/debridement/plastic repair.

Is anyone interested in this? I'm interested in publishing it. I've seen other products on the market. Mine wouldn't be a reprinting of Medicare regulations. It would be a more step-by-step, logical explanation of why one code is more appropriate over another in plain language.

Comments welcome.
Thanks.
WK

Soft tissue debridement (88304) vs. organ debridement

2010-10-13T17:45:00.000-07:00

Soft tissue debridement is a CPT-designated specimen but it does not pertain to organs that are defined as Level V or Level VI specimens. CPT is clear that soft tissue refers to muscle, connective tissue, nerve, any fat besides a lipoma, and anything else that isn't normally referred to as an organ, especially one defined specifically by CPT.

Coders often think that soft tissue is anything that isn't bone. CPT doesn't make that distinction. A stomach may not be made of bone, but a portion of stomach is not debrided off the rest of itself. It is resected or excised, which as discussed more than once in the archives, means essentially the same thing unless we are discussing a soft tissue mass or tumor.

A full-thickness removal of stomach or colon or pancreas or liver or lung or what-have-you is not a soft tissue debridement if recognizable tissue is revealed. If it is all necrotic cells, then a debridement code for undifferentiated soft tissue (88304) is in order. If the specimen is grossly or microscopically identified as stomach or colon or pancreas or liver or lung or what-have-you, an organ-specific resection code is probably more accurate.

The key to correctly describing surgical pathology specimens in code is to read CPT literally and not be led astray by the amount of physical work or intellectual labor involved in a particular diagnosis. CPT definitions are not concerned with the number of slides or the diagnosis. They are only concerned with the tissue at hand. CPT is mostly unconcerned with how a specimen is treated or what is anticipated. A stomach or colon resection is either for tumor or other than for tumor. If it is to remove dead stomach or intestine, it isn't a debridement. It is a resection other than for tumor. A partial pancreas resection is a partial pancreas resection whatever the reason. The same with a liver or a lung.

When you can point to the CPT definition and say, "This is what this is," you stand on solid ground. When you say, "This is what it's supposed to be," you don't even have a crutch. This applies to "upcoding" a specimen as much as it does to "downcoding." There's no such thing as either.

A specimen is either coded accurately or not. The more I examine the codes and read pathology reports, the more I am convinced the AMA is right in thinking just about everything is covered by the system as currently devised. The system may have its faults, but it does what it is supposed to do: report what the pathologist examines and diagnoses.

Vulva resection CPT 88309

2010-09-13T04:53:00.001-07:00

Level VI specimens represent what are theoretically the most complex of surgical pathology specimens. The complexity considered is only the anticipated average of technical and professional expertise required to examine and diagnose a particular specimen. Some specimens will require more work on the pathologists’ part and others will require less. The only consideration in assigning a code is whether or not the specimen is accurately described by the definition provided in CPT. If a specimen is a vulva resection, CPT provides a code for that without any nuances or qualifications. The specimen derived from a vulvectomy is specifically chosen for this example because it is a specimen that sometimes does not seem to merit “the highest code available.” While CPT is divided into numbered levels, the only criteria for assigning codes is the description of the specimen itself.

Vocal chord nodule excision (??)

2010-08-26T11:35:00.000-07:00

I wrote the other day about the differences between an excision and a resection.

A larynx is a CPT-designated organ that has a number of different level specimens assigned to it. Tissue removed from the larynx does not fall within the purview of soft tissue codes because CPT allows for more explicit descriptions. A biopsy of laryngeal tissues is explicitly described by Larynx, biopsy (88305). Just as a biopsy of a mass in the colon or kidney is coded as a biopsy of those organs, a biopsy of a laryngeal mass is also most accurately coded as 88305.

The vocal chords are a part of the larynx and they are not designated in CPT. This is, of course, the same issue I discussed the other day when considering a tracheal biopsy composed mostly of cartilage.

As discussed the other day, there is no discernible surgical difference between an excision or a resection. An excision of a mass from within the larynx is not a biopsy but it may seem less than the specimen described by Larynx, partial/total resection (88307). CPT makes no distinction between a simple excision or a complex resection regarding the larynx, only between a biopsy or a resection. Without the additional words 'simple' or 'extensive' preceding them, an excision is synonymous with a resection. Both a partial and total laryngeal resection fall under 88307 or, if you prefer, a partial or total excision.

Some sources advise thinking of a vocal chord nodule as an “unlisted” specimen in CPT. They further go on to code it as equivalent to being a Level V specimen, Soft tissue mass, biopsy or simple excision (88307). While this logic does provide a code of 88307 for an vocal chord nodule excision, it is the same code that would be used if the specimen was considered a Larynx, partial/total resection (88307), without regional lymph nodes.

By consistently following the principle of literal interpretation of CPT, codes are assigned based on a coherent method: The larynx, including its component parts, is specified by CPT. The size and complexity of a specimen resected (excised) from a larynx has no bearing on coding. The documentation must support that a true excision/resection is being performed and not an “excisional biopsy.” All biopsies of tissue in the larynx are correctly coded 88305. Anything else is a different code depending on whether regional lymph nodes are submitted or not.

You may disagree but I maintain that by adhering down to the most basic grammatical level of CPT's text, coding will be less confusing than inventing unlisted specimens that will eventually create confusion. Inviting exceptions to a strict interpretation leads to inconsistent thinking. Vocal chords are not unlisted; they are part of a larynx and should be treated as such. Because of this a biopsy of a vocal chord mass is not a Level V specimen.

Medical Billing Careers, Medical Coding Careers

2010-08-24T10:42:00.000-07:00

I don't usually let my other endeavors bleed over into this blog but I wrote a testimonial to our profession here for anyone interested. Make sure you also read today's other post on Surgical Pathology Coder on excision vs. resection below.

Cheers,
WK

Excision vs. resection

2010-08-24T10:06:00.000-07:00

Basically, the words excision and resection are synonymous. I'm ignoring breast specimens at the moment since they have their own issues, but these also benefit from a literal reading of CPT specimen descriptors in Surgical Pathology.

According to trustworthy Stedman's Medical Dictionary, an excision is "The act of cutting out; the surgical removal of part or all of a structure or organ." From the same source, a resection is 1. "A procedure performed for the specific purpose of removal, as in removal of articular ends of one or both bones forming a joint." or 2. "To remove a part."

CPT makes a distinction between the simple excision of a soft tissue mass and the extensive resection of a soft tissue tumor. Aside from these two CPT-designated definitions, the coding guidelines are mute as to any difference between an excision or a resection. If soft tissue tumor is not involved, an extensive resection can't be performed on it. The extensive resection of a soft tissue mass, may be possible but it is such a rare occurrence that we can safely disregard it and suggest that any soft tissue mass that doesn't involve tumor is best coded 88307. The difference between the two lies in the adjectives rather than the nouns.

An excision or resection of a colon mass (not suspected to be tumor) is coded 88307, Colon resection, other than for tumor, because the words excision and resection mean the same thing. Simplicity and extensiveness have no bearing on translating the specimen into code. This doesn't apply to an excisional biopsy. In that case, since the specimen is a biopsy, 88305 most accurately describes the specimen at hand.

In the next day or so I'll be discussing a more problematic specimen using the same logic to come to the same result. Stay tuned.

Trachea biopsy vs. cartilage shavings

2010-08-18T12:22:00.000-07:00

A biopsy taken from the trachea is correctly coded 88305. This is a CPT-designated specimen and as with any specimen designated by CPT, the only consideration in code assignment is if the descriptor matches the tissue on hand.

The trachea is made of cartilaginous elements with some supporting muscle, connective tissue and respiratory mucosa. Representative samples of tracheal cartilage that are submitted for investigative biopsy to determine the nature of any underlying pathology are NOT most accurately described as Cartilage shavings (88304). Any biopsy performed on tissue removed from the trachea is correctly coded 88305.

Cartilage shavings are normally the result of an orthopedic procedure. This doesn't always have to be the case, but it's the most common scenario. There is no expectation that examination and diagnosis of cartilage shavings will provide more than identification and the confirmation of a disease process. These are not normally investigative specimens though CPT doesn't differentiate as long as shavings are on hand. In fact, a cartilage biopsy is not a CPT-designated specimen. In the unlikely event cartilage is received for biopsy outside the trachea, a soft tissue code may be more appropriate if the documentation supports it. That code would be Soft tissue, other than tumor/mass/lipoma/debridement (88305). The result of the biopsy could be osteochondroma which is best described by the CPT-designated Bone, exostosis (88305) though actual bone may not be involved. Exostoses often have a cartilaginous element.

A literal interpretation of CPT demands that anything coded Cartilage shavings in fact be cartilage shavings. Needle cores and excisions are not shavings so they are not automatically Level III specimens (88304).

There are a lot of issues to keep in mind when looking at a specimen composed primarily of cartilage. That said, there is no reason to automatically defer to 88304 just because cartilage is present. As always the supporting documentation should leave no room for doubt why a particular code was assigned to a specimen.

Heart valve: 88305

2010-08-03T08:53:00.000-07:00

Heart valves themselves can be rather complicated specimens for pathology coders, especially if we over think them too much. Receiving a porcine heart valve probably isn't the hottest issue in your lab, but they do show up occasionally.

A biological artificial heart valve removed for replacement is composed of tissue and it is examined microscopically. Bearing this in mind, this specimen meets the criteria for a Level IV specimen and it is a “heart valve” regardless of the species of origin. CPT makes no distinction between a porcine heart valve or a human one for coding purposes.

There are apparently cow and horse transplants as well, somewhat different from the pig valve but the same idea would apply. If you have tissue that's examined grossly and microscopically for diagnosis, it can be coded regardless of what animal owned it first, a quadruped or a featherless biped, as long as it came out of a human body to be submitted to Pathology in the service of human patient care.

There are other heart valve coding issues, but we try to limit it to one head-scratcher a week.

Pathology coding is not Pathology billing

2010-07-22T08:57:00.000-07:00

"It is common to confuse billing with coding since the two disciplines are often co-mingled. Coding itself is a separate discipline that, beyond annual additions and deletions, changes little over time. In the service of billing, the rules and nuances of coding are subservient to contractual agreements and government regulations. It is the billing process that changes regularly and the practice of medical billing requires constant re-education in industry requirements."

Of course, ICD-10-CM is coming up soon, so this may not be the most accurate statement. Close enough though.

Gallbladder 88304

2010-07-20T02:14:00.000-07:00

A gallbladder removed for any reason and submitted to the Pathology Department for examination and diagnosis is correctly coded 88304. This specimen is usually the result of a cholecystectomy, a stand alone procedure undertaken for this reason alone. "Chole" refers to bile (gall) and "cysto-" refers to bladder. "Ectomy," of course, means the removal of the gallbladder. Rare instances of gallbladder biopsy would also be coded 88304 because the nature of the specimen remains gallbladder, a CPT descriptor without equivocation or elaboration.

Unlike some other organs, CPT doesn't differentiate between a gallbladder biopsy or a gallbladder resection. Nor is CPT concerned with a gallbladder removed for inflammation or one removed for tumor. Pathologic diagnosis of gallbladder tissue is the determinative factor in assigning the correct code to this specimen. Once a gallbladder is diagnosed, there is no more thinking to do. It is 88304 and time to code the next case.

The gallbladder may be received with an attached, incidental lymph node or may contain calculi. As with most incidental tissue, these are not usually coded separately. The Sept 2006 issue of CAP Today addressed the issue of incidental lymph node coding.

Conjunctiva biopsy/pterygium: 88304

2010-07-16T10:29:00.000-07:00

It's not the most common specimen received in a pathology lab, and because of that, it can cause some confusion.

A biopsy of the conjunctiva or the removal of a pterygium are correctly coded 88304. While a pterygium is consistent with other specimens described by 88304, this is the only biopsy specimen that is coded as a Level III exam. Care should be exercised that a conjunctiva biopsy doesn’t automatically get assigned a different code through habit or association.

88304 describes a conjunctiva biopsy and/or excision of a pterygium. Other conjunctival excisions, with the exception of “excisional biopsies,” do not fall under the same terms. Size, complexity, time spent on examination, resources expended to determine diagnosis, severity of condition or other mitigating factors have no influence on coding a conjunctiva biopsy as long as it is a biopsy that is being performed. If a true excision is being performed of something other than a pterygium, 88304 does not apply.

Newborn foreskin pathology coding

2010-07-08T14:47:00.001-07:00

88302 applies only to newborn circumcision and should not be confused with circumcision specimens obtained from other than newborns. CPT does not contain a definition of ‘newborn.‘ CAP has opined, based on the definition of ‘newborn‘ in Stedman’s Medical Dictionary, that 88302, foreskin, newborn, should be used when infants are less than 30 days old. ICD-9-CM does offer definitive guidance, stating that an infant is correctly reported as a newborn through the twenty-eight day following birth. Though the two coding systems are not formally linked, diagnosis codes are associated with procedure codes through matrices and coverage determinations maintained by CMS and other third party payers. Bearing that in mind, and in the interest of consistency, 88302 should be applied in accordance with ICD-9-CM’s guidelines; i.e. to all patients who are between the ages of 1-28 days. On the twenty-ninth day, the code 88304, foreskin, other than newborn, applies.

Unbundling pathology specimens

2010-06-29T12:10:00.000-07:00

Some specimens arrive containing more than one type of tissue with an indication from the surgeon that two diagnoses are requested. If these specimens would not normally be received together, the specimens are separately coded, i.e. they are “unbundled” into the component parts. Some specimens arrive with attached tissue different from the main specimen. If this tissue is more than a margin of a resection and it merits individual, it is unbundled as a distinct specimen in its own right.

Warning: If the surgeon marks a colon resected for tumor in two different places for individual diagnosis, these are not coded separately. The applicable code is 88309, colon resection for tumor.

There are cases where unbundling unlike specimens received together is required. A cystoprostatectomy is a complex procedure that involves removing the urinary bladder and the prostate gland at the same time. These organs are usually received together and attached, though neither is incidental to the other. CPT describes a urinary bladder resection as 88309 and a radical prostatectomy as 88309. If both bladder, prostate, and the prostates surrounding structures are examined and diagnosed, the most accurate description of these services is 88309 x2.

Bundling pathology specimens

2010-06-28T10:43:00.000-07:00

The unit of service in pathology coding is the specimen. The introduction to surgical pathology codes in CPT makes this clear.

Some specimens are composed of more than one type of tissue by their nature. When described in CPT, these tissues that would normally be coded separately are “bundled” into the more comprehensive code. Some specimens arrive with attached tissue that is incidental to the main specimen either it is a margin or it is tissue that was removed because of its intimate nature with the main specimen. Only one code is assigned to describe the main specimen since the attached tissue does not merit individual attention.

There are cases where bundling of specimens is mandated by CPT. For instance, regional lymph nodes removed during a larynx resection are always bundled into the comprehensive 88309, Larynx, partial/total resection - with regional lymph nodes. This is true whether the lymph nodes are received attached to the larynx or separately in their own container.

We'll cover unbundling tomorrow.

Pathology coding the right way.

2010-06-23T12:01:00.000-07:00

Here's what I see as being the role of codes in the reimbursement process for a pathology lab. It's pretty clear cut, but I get a lot of questions about how to maximize reimbursement. The answer is pretty simple: do it right the first time. There aren't any secret tricks. In fact, if anyone recommends ways to tweak the codes rather than improve the documentation I suggest you turn a deaf ear.

An outside agency reviewing a pathology lab’s records and codes will do so based on guidelines and statutes beyond the scope of what a typical pathologist considers while looking through a microscope. With that in mind, the underlying principle of this correct coding is that documentation unequivocally describes the procedures and findings provided by the lab in any given situation. Codes are assigned without assumptions or inferences to most accurately reflect what is literally written in the pathology report. The assigned codes will then be submitted (billed) accordingly to third party payers according to contractual and regulatory requirements. Third party payers will have no recourse to question the validity of the reported codes or the accuracy of the pathology laboratory's request for reimbursement. The lab will receive what money is justifiably due for medically necessary services provided.

The understanding and practice of basic coding principles based on available documentation is the primary strategy that the pathology lab employs to remain compliant in its contractual obligations and legal mandates. With correct codes applied at the time the final report is signed out, follow-up by the Compliance and Billing Departments can refine the given codes to payer-specific requirements. Correct coding at the outset ensures correct coding in the final product.

E codes in Pathology

2010-06-21T15:22:00.000-07:00

Here's what I have to say about using E-codes as diagnoses. Using these codes is optional as far as pathology coders are concerned and there's really no reason to deploy them unless you happen to be a stickler for detail and 100% accuracy. Using an E-code won't affect reimbursement unless you use it as your primary diagnosis, i.e. your justification of medical necessity. An E-code doesn't cut it. It may be part of ICD-9-CM but it isn't a diagnosis.

"Codes that start with E are not used to describe a diagnosis or clinical complaint. These codes are designed to provide supplementary information as to how injuries occurred. Unless the cause of injury is documented and relevant to the pathology report, use of these codes should be avoided."

If it isn't documented and it isn't relevant to the pathology report, don't bother looking it up or submitting it. Sometimes there is a valid reason for reporting the circumstances of how an injury was incurred. From a pathologist's viewpoint, the injury itself is the pertinent diagnosis. Let the clinician and emergency room code the circumstances.

Pathology and Lab reporting.

2010-06-18T10:31:00.000-07:00

We've had some questions as to why CPT is used and what it is exactly. CPT is the abbreviation of Common Procedural Terminology, a standardized list of medical procedures and corresponding codes used to report services. The uses aren't limited to billing but also the compilation of statistics for various medical research and utilization studies. CPT is owned and maintained by the American Medical Association which maintains the copyright to its contents.

CPT contains seven main divisions, the most pertinent to pathologists being Pathology and Laboratory section that contains current contains codes 80047 through 89398. This section contains codes for drug testing, evocative/suppression testing, chemistry, hematology studies, immunology, tissue typing, transfusion medicine, microbiology, anatomic pathology, cytopathology, cytogenetic studies, surgical pathology, in vivo procedures, reproductive medicine, and codes for clinical and pathological consultations.

CPT is used to to describe medical services regardless of the specialty of the provider. A pathologist who performs a minor surgical procedure, a fine needle aspiration for example, will report performing that procedure though the code for FNA falls under the Surgery heading rather than Pathology and Laboratory. Likewise, in the uncommon event that a pathologist evaluates a patient in person, the appropriate evaluation and management code is reported and billed.

Apologies for the long absence. I am sure to be updating this more regularly in the coming months since I am hard at work on a book on this oft-neglected section of the coding system.

Soft tissue biopsy: 88305?

2010-05-04T17:36:00.001-07:00

We tend to use the phrase ‘soft tissue biopsy’ as a kind of short hand to mean 88305, but is it? CPT defines soft tissue a number of ways.

There is a soft tissue debridement which is translated as 88304. There is a soft tissue lipoma, also 88304. There is a soft tissue mass that is either biopsied or simply excised; that’s 88307. There is a soft tissue tumor that’s been extensively resected and CPT calls that 8309.

If your soft tissue is none of these things, CPT says it is soft tissue other than tumor, mass, lipoma or debridement: 88305. Note: a soft tissue biopsy is not 88305. If you biopsy a lipoma or a debridement, it’s 88304. If you biopsy a mass, it’s 88307. If you biopsy a tumor that isn’t a mass, a lipoma or debridement, it’s not an extensive resection.

Undifferentiated soft tissue is correctly coded as 88305. The tissue may be suspicious, but if it hasn’t arranged itself into a mass, it is 88305. A diagnosis of cancer doesn’t matter. Most tumors arrange themselves in masses and when they do they are correctly coded as 88307. No mass? 88305.

Can you biopsy debrided tissue? Sure. 88304. Can you needle biopsy a lipoma? Of course. 88304. Can you biopsy soft tissue? Yes. 88305. As long as it isn’t a debridement, a lipoma or a mass, 88305 applies. As long as you think of it as undifferentiated soft tissue, you’ll code this specimen correctly.

Diagnosing a gross exam (88300)

2010-04-20T12:28:00.000-07:00

Someone asked me about my opinion regarding specifically stating a diagnosis in the report and why I feel pretty strongly about it. I was reviewing some RAC results recently, specifically about 99211. When the RAC found against the provider, it wasn’t a matter of medical necessity, it was a matter of documentation. One case in particular caught my eye. The patient had a prothrombin time performed in the office, the results reviewed and his medication dosage adjusted accordingly. All of that was documented, but the beginning of the note read, “Only labs performed.” That was enough to invalidate any evaluation and management charge.

Let’s look at what CPT has to say about surgical pathology codes (copyright the AMA): “A specimen is defined as tissue or tissues that is (are) submitted for individual examination and pathologic diagnosis.” Further: “Service code 88300 is used for any specimen that in the opinion of the pathologist can be accurately diagnosed without microscopic examination.”

Some wiseacre will make the argument that foreign bodies are not tissue so they can’t be reported, but we’re not going to address that today. What’s required for any level of surgical pathology code is a reported exam and a diagnosis. What’s required for 88300 is a gross exam and a diagnosis. An E/M note missing a history and physical can’t be reported because it is missing a critical piece of information. A pathology code without a diagnosis can’t be reported for the same reason.

I went looking for diagnoses on gross exams recently and my favorite, by far, was “inanimate object” to describe a port-a-cath that was removed from a patient. There was a full description of what was submitted, including measurements and serial number. There was a diagnosis of inanimate object. There was no question that everything required was provided to the referring physician.

Maybe I’m overreacting or advising too much documentation. Is there really such a thing in an audit? I don’t think so.

Coding a gross only exam

2010-04-18T12:55:00.000-07:00

A gross exam that renders a diagnosis is coded 88300 regardless of the specimen type. It doesn’t happen often, but an extensive resection of a soft tissue tumor would be coded 88300 if no blocks were prepared, no slides stained, and no microscope employed.

The key here is that a gross exam is used to provide a diagnosis. If the report states “Gross exam only” is that a diagnosis? Nope. CPT is pretty clear that to report and charge a medically necessary service a physician (pathologist in this case) provides a diagnosis to further the plan of care.

Even a foreign body removed for gross exam should be diagnosed. What’s the diagnosis in the case of a bullet, for instance? Besides describing the bullet in the summary of the exam, the diagnosis is simply “Bullet.”

The report should not be written like so: “Pathologic Diagnosis” Specimen labeled “BULLET”: Gross only exam.”

No diagnosis equals no pathology described equals no code equals no charge.

Esophageal fistula

2010-04-12T14:26:00.000-07:00

It's been over a month and that's no way to write a blog, especially one on a subject with a shortage of guidelines. I stumbled over an example today which reminded me that I am supposed to be doing this weekly at least.

The surgery was for an esophagus resection. The complication was that the section of esophagus (about 10cm long) that was removed and submitted to pathology had a fistula. This is uncommon and I won’t bore you with the clinical history of how it came about. The fact of the matter is we had to code a specimen that could be interpreted two different ways.

CPT designates two different specimen types that can apply, but as I’ll come back to time and again, by reading the codes literally, appropriate code selection becomes simpler than is usually assumed.

Per CPT a fistula is 88304. An esophagus resection is 88309. That’s quite a divergence. You’ll notice there is no qualifying information for the level VI specimen (88309). It doesn’t specify that the esophagus is neoplastic or that it is removed for tumor. You’ll also notice there is no qualifying information for the level III specimen either, so what do we have on our hands?

Level III is a specimen along the lines of an abcess or a debridement, two other specified designations along with fistula. While the esophagus may have been resected for fistula, there is more going on than just debriding some necrotic or infected tissue. In fact, the proximal and distal margins were inked and examined. While the specimen was diagnosed as an esophagus involving fistula, the margins were diagnosed as being viable and without pathologic change. That’s the clincher. The fact that this is an esophagus resection and is treated as such, over rides the fistula; the organ itself is being diagnoses rather than the process that involves only part of the organ.

Verdict: 88309.

Grammar

2010-02-09T14:32:00.000-08:00

Surgical Pathology services are coded by specimen. The six basic specimen codes are the foundation off which everything else is built. As I mentioned last post, there are 175 different defined specimen types. How different are they? As different as a bone fragment and a bone biopsy. As different as a fistula and a small intestine resected for fistula. As different as an inflammatory nasal polyp and a nasopharynx biopsy.

I’ve often said that coding is more art than science. Coding is a language with its own grammar. Like English-speakers, different coders use grammatical rules differently. My bills will have a different flavor from yours based on experience and insight. Despite the differences, they’ll be mutually intelligible and when I work backward from your bill to the documentation, or you work from mine, both of us will understand what the other is saying and we’ll both say, “Aha!” That’s the beauty of it.

Most of the time, translating medical services into code is cut and dried, rote, hamster-in-a-wheel work. If you find coding challenging, you are probably over thinking it. Not that you shouldn’t be thinking; it is a job that requires some smarts, attention to detail, and the ability not to be easily bored. It’s the fuzzy cases that keep me from being easily bored.

So we’ve got 175 defined specimens broken into six levels of service. They fall into the following hierarchy:

88300. Gross exam. This is the easiest to code. No matter what it is, if a microscope wasn’t used, use 88300 and move along.

88302. There are 12 defined specimens.

88304. There are 43 defined specimens.

88305. There are 67 defined specimens.

88307. There are 35 defined specimens.

88309. There are 19 defined specimens.

Do the math. Welcome to the world of medical coding, where the only sure thing is that things don’t add up. It all works out in the end though.

The six code foundation

2010-01-31T12:47:00.000-08:00

I was talking someone who was going to school for medical coding. I described how in Surgical Pathology, we have basically 6 six codes with which we report services.

“Six codes!” he said. “That must be easy.”

It is easy sometimes. It is also complicated. These six codes are supposed to describe various levels of examination. They cover 175 listed specimen types. These are actually two contradictory ways of looking at what a pathologist does. As the guiding authorities have pointed out time and again, the amount of work a pathologist does has no bearing on code selection. The idea of a Level IV Exam, is misleading.

The specimen at hand determines code selection. If a specific specimen isn’t listed in CPT, a coder is advised to select the level of service most appropriate to what is on hand. This is often easier said than done.

The unit of service is the specimen, that is: distinct tissue submitted by a surgeon for evaluation. The surgeon’s intent isn’t always cut and dried. Sometimes, tissues so dissimilar are received together that each merits a separate report and diagnosis. How does a coder determine if this is one unit of service or two? There are ways.

There are few hard rules when it comes to coding Surgical Pathology services. There isn’t a lot of guidance out there either. What rulings there are from the AMA and from CAP, are few, narrow, and pithy. They can also be contradictory. Off the top of my head, I can think of two instances where the CAP has reversed its position over the course of the past decade. All the answers are in the archives though, the old advice and the new, separated by years without reference to each other.

Make sure you have the most current information.

CPT belongs to AMA

2010-01-24T14:05:00.000-08:00

As anyone familiar with the medical reporting industry knows, CPT (Common Procedural Terminolgy) is copyrighted by the AMA (American Medical Association). CPT is a list of five-digit codes used to describe medical services provided by health care practitioners to their patient populations. As the scope and nature of services is constantly changing, so are the codes. CPT is updated annually, each new edition going into effect on January 1 of each year.

Who uses these codes beyond medical coders? Their primary purpose is to report delivered services to third party payers, i.e. insurance companies and government agencies (Medicare and Medicaid). There are other statistical uses but these are not as fully realized as the use of the coding system in insurance reimbursement.

This site has no connection with the AMA beyond using CPT. We will refer to the descriptions of each code in CPT and the guidance that the code book provides. Quotations are used for illustration purposes only and we do not guarantee that our interpretation is the one the AMA intended when it published the latest version of CPT. We do, however, endeavor to research each code and issue to summarize how best to report a service in code as intended.

This site is not affiliated with Medicare, Medicaid, or any private insurance company. All viewpoints expressed are my own, a professional medical coder with over twenty years experience. I am currently working in Pathology, a small sliver of the CPT system, but one that presents any number of challenges.

Matthew King, CPC, CCS-P