Pathologic Testing on Bone Marrow
Understand specimen collection procedures for reporting you can count on.
Robert Cassels, BA, CPC, and Shelley C. Safian, PhD, CPC-H, CPC-I, CCS-P
Although not performed as commonly as blood tests or urinalysis (because obtaining the specimen is complex), pathologic examination of a patient’s bone marrow has many possible uses, including:
- As a diagnostic tool for suspected myeloma, leukemia, myelodysplastic syndromes, and myeloproliferative disorders
- To assess a current diagnosis of thrombocytopenia, anemia, or leukopenia
- To measure quantities of stored iron and marrow cellularity
- To determine neoplasm, infection, fibrosis, or other infiltrative bone disease
- To enable staging of lymphoma and/or other malignant neoplasms
A patient may have abnormal blood counts without an identifiable explanation, or have other abnormal cells evidenced in circulating blood. These, as well as a current bone marrow-related disease diagnosis (such as lymphoma), or indications that a malignancy has metastasized into the marrow, are standard justifications for obtaining and studying a bone marrow specimen. Typically, the specimen is taken from the posterior superior iliac spine of the pelvis to acquire a sample of the blood-forming cells in the marrow space. Evaluation of a specimen taken by biopsy is considered to be more accurate than one obtained by aspiration because the quantity of material gathered is greater, and more likely to represent a wider scope of sampling.
Specimen Extraction Coding
When coding for bone marrow biopsy, the first procedure code to report is that for obtaining the specimen, using either 38220 Bone marrow; aspiration only or 38221 Bone marrow, biopsy, needle or trocar.
Note that the abstraction of bone marrow from a patient is not performed solely for the lab, and it’s very important to identify from the documentation not only how the bone marrow was taken, but for what purpose. For example, bone marrow aspiration for platelet rich stem cell injections are not reported with 38220, but with 0232T Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when preformed. Harvesting bone marrow for transplantation is reported with either 38230 Bone marrow harvesting for transplantation; allogeneic or 38232 Bone marrow harvesting for transplantation; autologous.
When both a bone marrow biopsy and a bone marrow aspiration are performed on a Medicare beneficiary during the same encounter, do not claim 38220. Instead, report G0364 Bone marrow aspiration performed with bone marrow biopsy through the same incision on the same date of service.
Next, the specimen will be sent to the laboratory for analysis. A bone marrow specimen obtained by either biopsy or aspiration can enable a hematologist/pathologist to investigate the patient’s hematopoiesis (the process of forming blood cells), as well as the shape, size, and quantity of red and white blood cells (RBCs and WBCs) and megakaryocytes (very large bone marrow cells that produce blood platelets). Blood cell formation is primarily the responsibility of the red bone marrow, specifically in the sternum, ribs, and the iliac bones (pelvis).
Code 88305 Level IV – Surgical pathology, gross and microscopic examination describes both evaluation of the bone marrow biopsy specimen by the naked eye (known as gross examination) and visualization of the specimen using a microscope. When the documentation states that the specimen was obtained by aspiration, report the analysis with 85097 Bone marrow, smear interpretation, instead of 88305.
It’s not uncommon for a decalcification procedure and/or iron staining to be performed at the same time as the surgical pathology examination. When documentation confirms this, report these procedures separately using +88311 Decalcification procedure (List separately in addition to code for surgical pathology examination) and/or 88313 Special stain including interpretation and report; Group II, all other (eg, iron, trichrome) except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry.
Per CPT® parenthetical instruction, report one unit of 88313 for each special stain on each surgical pathology block, cytologic specimen, or hematologic smear. Check documentation or query the testing pathologist to ensure the notes are clear as to how many blocks, specimens, or smears were tested. This will help you to report the accurate number of codes/units.
Immunophenotyping by flow cytometry can identify cell-specific antibodies, enabling more accurate determination of cell percentages and identification of abnormal cell patterns. Report this test using 88184 Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker and +88185 Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker (List separately in addition to code for first marker), as appropriate.
Because 88184 and 88185 are specifically limited to the technical component only, you’ll need a code to report the interpretation service separately. Note, modifiers TC Technical component and 26 Professional component are not necessary because these details are already included in the code descriptors, as follows:
88187 Flow cytometry, interpretation; 2 to 8 markers
88188 9 to 15 markers
88189 16 or more markers
Fluorescent in situ hybridization (FISH) analysis (88365 In situ hybridization (eg, FISH), each probe) is usually performed after the analysis of the bone marrow, the results of which will direct the specific deoxyribonucleic acid probes to be conducted. FISH analysis is better than an overall karyotype test because it can find smaller pieces of chromosomes that may be missing or have extra copies.
Put It All Together
To make sense of it all, let’s consider a couple of realistic encounters and how to accurately report them.
A 43-year-old female has a history of chronic myeloid leukemia. She came to our facility today for a bone marrow aspiration, right side posterior iliac crest. A 15-gauge needle was used to obtain the aspirate including an aspirate clot. The patient tolerated the procedure well.
ICD-9-CM Diagnosis Code:
V10.62Personal history of myeloid leukemia
ICD-10-CM Diagnosis Code:
Z85.6Personal history of leukemia
Obtaining the Specimen:
The following specimens were reviewed: peripheral smear of bone marrow aspirate and clot section; iron stain.
A 77-year-old male has multiple myeloma, and came to our facility for a bone marrow core biopsy, touch preparation. Biopsy site is left posterior iliac crest.
ICD-9-CM Diagnosis Code:
203.00Multiple myeloma, without mention of having achieved remission
ICD-10-CM Diagnosis Code:
C90.00Multiple myeloma not having achieved remission
Obtaining the Specimen:
Immunophenotyping (flow cytometry) performed, two markers
The Results Are In
As mentioned, bone marrow analysis includes a quantification of megakaryocytes. A patient who has recently suffered a hemorrhage, has acute or chronic myeloid leukemia, or who has been diagnosed with secondary hypersplenism due to portal hypertension, is expected to have an increase in the percentage of megakaryocytes present in the bone marrow. Patients who have gone through (or are going through) chemotherapy, radiation therapy, or some specific drug therapies, and those with aplastic anemia, or infiltrative neoplastic or fibrotic marrow disease, will have a reduced number of megakaryocytes (normal range is 0-0.4 percent).
Patients with lymphoma, lymphocytic leukemia, mycoplasma infections, a viral and/or chronic infection, multiple myelomas, lymphomas, rheumatic fever, or another chronic inflammatory disease will have a greater than the normal percentage of lymphocytes. Normal range of lymphocytes is 11.1-23.2 percent.
Other conditions that may be confirmed or indicated by the results of a bone marrow analysis include:
Anemia: Iron deficiency is only one cause of an abnormally low count of hemoglobin, hematocrit, and/or RBCs. Low RBC volume reduces the amount of oxygen being transported, causing tissue hypoxia (low levels of oxygen). Classic signs and symptoms include tachycardia, dyspnea, and sometimes fatigue.
Leukemia: The presence of malignant cells within the bone marrow that produces blood cells (hematopoietic tissues), causing a reduction in the production of RBCs, WBCs, and platelets. This anemic state makes the patient very susceptible to infections and hemorrhaging. There are several types of leukemia, including myeloid leukemia and monocytic leukemia.
Thrombocytopenia: This is a low platelet count, most often due to increased platelet destruction, decreased platelet production, or malfunctioning platelets. Underlying conditions might include a case of splenomegaly (enlarged spleen) when bone marrow is destroyed by medication, chemotherapy or radiation therapy, or aplastic anemia.
Robert Cassels, BA, CPC, works as an outpatient coder at the Orlando VA Medical Center where he codes a wide variety of encounters. He spent several years specializing in dermatology coding. He is a member of the Orlando, Fla., local chapter.
Shelley C. Safian, PhD, CPC-H, CPC-I, CCS-P, teaches health information management and coding. She writes a monthly Q&A column and several articles each year on various aspects of coding and is the author of six textbooks. Safian has a Doctor of Philosophy in Health Care Administration and is an ICD-10-CM/PCS trainer. She is a member of the Orlando, Fla., local chapter.