Pathology/Lab Coding Alert

Specimens, blocks, sites -- if you don't know the unit of service, you could be leaving money on the table. Ramp up your intraoperative consultation coding with the following advice from our experts:

All consultations require the 3 R's -- request (from treating physician), render (medical opinion) and report (findings). Although you shouldn't even think about reporting a pathology consultation during surgery if you don't have documentation of the 3 Rs, that's not all you need to know.

"The nature of an intraoperative consultation is that the pathologist provides immediate feedback to the surgeon during the surgical procedure," says Melissa Sinclair, CPC, an independent consultant based in Denver.

The surgeon will use the pathologist's findings to help determine the appropriate course of action while the patient is still on the operating table. "For instance, a preliminary diagnosis of malignancy at the time of surgery could result in a more extensive resection," Sinclair says.

CPT provides five codes to describe intraoperative pathology consultations:

- 88329 -- Pathology consultation during surgery

- 88331 -- - first tissue block, with frozen section(s), single specimen

- 88332 -- - each additional tissue block with frozen section(s)

- 88333 -- - cytologic examination (e.g., touch prep, squash prep), initial site

- 88334 -- - cytologic examination (e.g., touch prep, squash prep), each additional site.

If the consultation involves only a gross tissue examination by the pathologist, use 88329.

"For instance, we might not do a microscopic exam during surgery for a bowel resection that includes a distinct lesion and enough normal mucosa to diagnose clear margins," says R.M. Stainton, Jr., MD, president of Doctors- Anatomic Pathology Services in Jonesboro, Ark.

Red flag: When the pathologist performs a gross and microscopic exam (frozen sections or touch preps) during surgery for a single specimen, you should not list 88329 in addition to the other code(s). CPT convention indicates that the indented codes (88331-88334) include the service described by the parent code (88329).

When a surgeon requests an immediate tumor evaluation during surgery, the pathologist often examines frozen sections to arrive at a preliminary diagnosis. To code these services correctly, you need to understand the preparation method and the unit of service.

The surgeon submits a tissue specimen, which the lab may process by flash freezing into one or multiple blocks -- these are tissue blocks. For each block, the pathologist may examine multiple slides of thin sections cut from the frozen tissue block -- these are frozen sections.

Don't miss: The unit of service for 88331 and 88332 is the frozen tissue block, not the specimen or the frozen section slide. Caveat: You have to keep track of specimens, too, because counting blocks starts over every time you encounter a new specimen.

Do this: Use 88331 to report the pathologist's evaluation during surgery of any number of frozen sections from the first (or only) tissue block from a specific specimen.

Then do this: If the pathologist examines frozen section slides from an additional frozen tissue block(s) from the same specimen, use 88332 for a second or subsequent tissue block from the same specimen.

Repeat as necessary: If the pathologist consults on a separate specimen later in the same surgery, such as a different margin resection, you should repeat the same coding sequence. "Code an additional 88331 for the first block of the new specimen and additional 88332(s) for any subsequent block(s)," Sinclair says.

Sometimes the pathologist will use a touch or squash preparation to evaluate tissue during surgery. "The process involves pressing a glass slide against the cut surface of the specimen, then staining and placing a cover slip on the slide," Sinclair says.

Site parallels block: Similar to frozen sections, CPT provides two codes for intraoperative touch preps: 88333 and 88334. For touch preps, however, the unit of service is the site, not the block (as it is for frozen sections).

Do this: Use 88333 to report the pathologist's evaluation during surgery of the touch prep slide(s) from the first site of an excision specimen.

Then do this: If the pathologist examines touch prep slides from additional sites of the same specimen, use 88334 for a second or subsequent touch prep site.

Repeat as necessary: If the pathologist consults on a separate specimen later in the same surgery, such as a different lymph node, you should repeat the same coding sequence. Heads up: Because CPT provides a specific code for touch preps during surgery, you should not use the other CPT touch-prep code 88161 (Cytopathology, smears, any other source; preparation, screening and interpretation) when your pathologist performs the service as part of an intraoperative consultation.

What if the pathologist evaluates frozen sections and touch preps during an intraoperative consultation on the same specimen?

No problem: According to CPT instructions, reporting such a scenario shouldn't be an issue. CPT provides a text note that instructs you how to code both services: "For intraoperative consultation on a specimen requiring both frozen section and cytologic evaluation, use 88331 and 88334."

Problem: CMS- Correct Coding Initiative (CCI) bundles 88331 and 88334 as a column 1/column 2 edit pair, meaning that you should not report the two codes together. Although listed with a modifier indicator of "1," which means you can override the edit pair, you need to understand when you can legitimately do so.

Solution: Remember your units of service -- it is not the specimen for frozen sections or touch preps. Rather, it is the block or the site. "If the pathologist evaluates frozen sections from one site and touch preps from a different site on the same specimen, you can override the 88331-88334 edit using modifier 59 (Distinct procedural service)," Sinclair says.

How to do it: According to CPT instruction, you should list the "first" frozen section code -- 88331 -- and the "each additional site" touch prep code -- 88334. "You shouldn't use both -initial site- codes -- 88331 and 88333 -- because the two sites are from the same specimen," Stainton says. You-ll have to append modifier 59 to 88334 to override the CCI edit pair.

Document different sites: To justify 88331 and 88334 charges for a single specimen, you must provide complete and unambiguous documentation. The pathologist must uniquely identify the site subjected to frozen section and each margin or other site used for touch preps.