Pathology/Lab Coding Alert

Identify biopsy, resection, or bundled.

Missing a lymph-node-resection exam could cost your pathology practice $270, but separately reporting bundled lymph nodes could cost you a claim denial.

Don’t be intimidated: Four easy steps can help you master written and unwritten rules to perfect coding for the following services:

• 88305 (Level IV - Surgical pathology, gross and microscopic examination; Lymph node, biopsy)
• 88307 (Level V - Surgical pathology, gross and microscopic examination; Lymph nodes, regional resection).

Exception: Sentinel lymph node biopsy (88307 … Sentinel lymph node) is beyond the scope of this article.

Step 1: Distinguish 88305 and 88307

Code 88305 describes a single lymph node that the physician submits to the pathologist for standard (not sentinel) examination and diagnosis. If the surgeon submits multiple, individually identified lymph nodes, each node earns a single unit of 88305.

But usually when the pathologist receives multiple lymph nodes, the surgeon indicates the region of origin and does not separately identify each node. In these cases, you should report code 88307 for a regional resection instead of multiple units of 88305.

For instance: The surgeon might indicate a total pelvic lymphadenectomy, which includes the bilateral external iliac, internal iliac (hypogastric), and obturator nodes, according to Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, director of operations with Encounter Telehealth in Omaha, Nebraska.

On the other hand: “If the surgeon separately identifies distinct resection specimens, each containing multiple nodes, such as left external iliac resection and left hypogastric resection, you can report multiple units of 88307,” says R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark.

Coders often ask, how do you report two lymph nodes? Your best bet is to follow the surgeon’s documentation regarding whether the specimen is a regional resection (88307), or two distinctly-identified lymph-node biopsy specimens (88305x2).

Step 2: Look for CPT^® Bundles

You shouldn’t report 88305 or 88307 for lymph node biopsy or resection in addition to the primary specimen code when the CPT® definition includes lymph nodes.

Get familiar with the following specimens that include the lymph node exam — by definition:

• 88309 (Level VI - Surgical pathology, gross and microscopic examination, Breast, mastectomy - with regional lymph nodes)
• 88309 (...Larynx, partial/total resection - with regional lymph nodes).

“Other than a sentinel lymph node biopsy, you should never unbundle lymph nodes included in a radical breast mastectomy or laryngectomy specimen,” Stainton says.

Tip: This restriction doesn’t apply generally to the anatomic site, such as breast, but specifically to the procedure code that lists the lymph nodes as part of the specimen, such as total breast mastectomy.

For instance: If the pathologist examines a breast biopsy specimen and an axillary lymphadenectomy, you may separately report both services as 88305 (… Breast, biopsy, not requiring microscopic evaluation of surgical margins) and 88307 (… Lymph nodes, regional resection). You should not artificially bundle the two specimens into an 88309 service.

Step 3: Acknowledge ‘Unwritten’ Rules

Although CPT^® lists only two specimens that “include” associated lymph nodes, industry standards acknowledged by the College of American Pathologists indicate several other specimens that routinely involve associated lymph nodes. For the following specimens that commonly come to the pathologist with lymph nodes, you should not separately bill a lymph-node biopsy or resection:

• 88304 (Level III - Surgical pathology, gross and microscopic examination, gallbladder)
• 88307 (... colon, segmental resection, other than for tumor)
• 88309 (... colon, segmental resection for tumor or total resection).

Exception: If the surgeon submits a separately-identified lymph node or regional lymph resection from a different body site, you can code for that work in addition to the preceding specimens. For example, you can separately bill lymph nodes (88305 or 88307) when the surgeon submits a partial colectomy specimen for Crohn’s (88307) with retroperitoneal or other un-associated lymph nodes.

Step 4 Double Check ‘Attached’

The basis of the “unwritten rule” for codes listed in Step 3 is that those specimens typically come with attached lymph nodes, so you should consider those notes part of the specimen.

Following that same logic, coding authorities advise that you should not unbundle attached lymph nodes for billing purposes if the primary specimen ordinarily comes with attached lymph nodes. The following specimens and attached lymph nodes often follow this convention:

• 88305 (... spleen) includes attached splenic lymph nodes
• 88307 (... liver, partial resection) includes attached hepatic, cystic and phrenic lymph nodes
• 88309 (... lung - total/lobe/segment resection) includes attached hilar and intrapulmonary nodes
• 88309 (... pancreas, total/subtotal resection) includes attached pancreatic and pyloric lymph nodes.

Proviso: Although the pathologist may receive the preceding specimens with attached nodes, you may not always need to bundle the lymph nodes. “For instance, if the surgeon individually identifies the associated nodes, by a separate container, a marking such as a suture, a mention in the op report, or other means, you can separately charge the appropriate lymph node code 88305 or 88307,” Stainton says.

Step 5: Know These Common Exceptions

“Many surgical specimens don’t ordinarily come to pathology with attached lymph nodes, so in rare cases that the surgeon submits the specimen, such as bone, and also submits lymph node(s), you may separately charge an 88305 or 88307,” Stainton says.

Exception: You should not separately code an “incidental” node or two discovered as part of the pathology exam of the primary specimen.

The following list includes specimens that don’t typically involve surrounding tissue and associated lymph nodes:

• Bone (88305 … exostosis; 88307 … biopsy or pathologic fracture fragment; 88309 … resection)
• Cystectomy (88309 ... urinary bladder, partial/total resection)
• Esophagectomy (88309 ...esophagus, partial/total resection)
• Gastrectomy (88307 ... Stomach, subtotal/total resection, other than for tumor; 88309, … for tumor)
• Hysterectomy (88307 ... uterus, with or without tubes and ovaries, other than neoplastic/prolapse; 88309 … neoplastic)
• Nephrectomy (88307 ... kidney, partial/total nephrectomy)
• Oophorectomy (88305 ... ovary with or without tube, non-neoplastic; 88307 ... neoplastic)
• Prostatectomy (88307 ... prostate, except radical resection; 88309 ... radical resection)
• Skin (88305 ...skin, other than cyst/tag/debridement/ plastic repair)
• Soft tissue mass (88307 ... soft tissue mass (except lipoma), biopsy/simple excision; 88309 ... soft tissue tumor, extensive resection)
• Thyroidectomy (88307 ... thyroid, total/lobe).

Opportunity: “You can separately code for lymph nodes received with one of the preceding specimens, in most cases,” according to Stainton.