Pathology/Lab Coding Alert

Coding for pathology consultation during surgery can be a source of confusion for many. A proper understanding of the work described by each of the pathology codes 88329-88332 is imperative for proper reimbursement. Coders must also know what services are not included because these may be reported separately.

As with any consultation, the family of pathology codes 88329-88332 involves a request for service, the rendering of a medical judgment, and a report. But the specific nature of these codes is that the pathologist is providing immediate feedback to the surgeon during the procedure, reports R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services, an independent pathology laboratory in Jonesboro, Ark. In this way, the information supplied by the pathologist can guide the surgeons decisions regarding course of the surgery.

The pathologists consultation immediately may confirm a neoplasm for resection, identify metastases, or indicate whether the margins of a resection are clear. The pathology consultation during surgery can also let the surgeon know if an adequate specimen has been obtained for diagnosis, says Stainton.

Explanation of Codes for Pathology During Surgery

1. Code 88329: Code 88329 (pathology consultation during surgery) represents gross examination only, reports Elizabeth Sheppard, HT (ASCP), manager of anatomic pathology at Wake Forest University Baptist Medical Center in Winston Salem, N.C. We use this code most often when a pathologist is asked for a quick look at a specimen or a margin during surgery, without giving a definitive analysis.

Stainton adds, We use 88329 to describe the gross examination of margins for a bowel resection. This specimen typically includes an obvious lesion, and several centimeters of normal mucosa before the margins, so a gross examination is all that is required. We also use 88329 to document a foreign body.

2. Code 88331: Use 88331 (pathology consultation during surgery; with frozen section[s], single specimen) to report the pathologists evaluation during surgery of any number of frozen sections from a tissue block. A block is a portion of tissue that has been prepared for sectioning, in this case by freezing. Frozen sections are thin slices cut from the block. Evaluating frozen sections from a tissue block often is used for rapid microscopic diagnosis.

3. Code 88332: Use CPT 88332 (pathology consultation during surgery; each additional tissue block with frozen section[s]) to report the pathologists evaluation during surgery of any number of frozen sections from a second or subsequent tissue block from the same specimen.

Report 88331 and 88332 for frozen sections of the same specimen, taken from different tissue blocks, advises Sheppard. Frozen sections from the first block are reported with 88331, and any subsequent blocks submitted for frozen section would be an additional 88332 for each of the blocks examined, she continues.

If the pathologist consults on a separate specimen later in the same surgery, such as a different margin resection, the same type of coding is repeated. Code an additional 88331 for the first block of the new specimen and additional 88332(s) for any subsequent block(s).

Coding for Additional Services

If other procedures are used during or subsequent to a pathology consultation during surgery, report those services using the appropriate CPT codes. For example, a pathologist may use a touch prep (88161, cytopathology, smears, any other source; preparation, screening and interpretation) or may examine a cell sample (88104, cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation) during the intraoperative consultation. Report those services separately.

The gross or frozen section evaluation during surgery does not replace the definitive surgical pathology evaluation of the tissue. Report the services using the surgical pathology codes 88302-88309, depending on the specimen and the level of service, in addition to the consultation codes (88329-88332). The surgical pathology codes 88302-88309 involve the microscopic evaluation of the tissue using permanent sections from blocks encased in a supporting medium such as paraffin, and include diagnosis and reporting.

Clinical Examples

Example 1: A pathologist receives a skin specimen for frozen section evaluation of margins during surgery and for diagnosis. Frozen sections from two different tissue blocks are required to evaluate the excision. Based on sections from these blocks, the pathologist reports to the surgeon that the posterior margin is incompletely excised. The codes for this service would be one unit of 88331 and one unit of 88332. For the definitive diagnosis of the skin specimen, a basal cell carcinoma (173.x [x denotes body site], other malignant neoplasm of skin), the pathologist also would report 88305 (skin, other than cyst/tag/debridement/plastic repair).

Suppose that later during the surgery, the pathologist receives an additional portion of the posterior margin. This represents a new specimen because its separately identified and submitted for evaluation and reporting, reports Stainton. Frozen sections are prepared from a single tissue block, and the pathologist reports on the margins, which is reported as 88331. Assuming a pathological examination and report is performed for this second specimen of the posterior margin, 88305 also would be reported.

Note that the second 88331 should be reported with modifier -59 (distinct procedural service) to avoid the appearance of duplicate billing. The modifier indicates that the second specimen represents a different session, different procedure, different site ... separate excision ... or separate lesion, as stated in the CPT.

Example 2: A pathologist evaluates a transverse colon segment during surgery. During gross examination, the pathologist identifies a tumor and renders a judgment that margins are clear. Report this service using 88329. Following the consultation during surgery, the pathologist carries out a gross and microscopic examination of the specimen. Report this service as 88309 (Level IV surgical pathology, gross and microscopic examination; colon, segmental resection for tumor).

Example 3: A pathologist evaluates a thyroid specimen during surgery. The pathologist examines the tissue and selects two portions to prepare as blocks for frozen sections. Additionally, a touch prep might be used to show intranuclear inclusions and linear grooves that are helpful in identifying the type of tumor, explains Stainton. Later, the pathologist evaluates and reports a definitive diagnosis for the thyroid specimen.

Code this scenario 88331 for the frozen sections from the first block, and 88332 for frozen sections from the second block. In addition, report one unit of 88161 for the touch prep, and use the surgical pathology code 88307 (Level V surgical pathology, gross and microscopic examination; thyroid, total/lobe) for the definitive examination of the surgical specimen.

Example 4: A needle core biopsy is taken from a lung lesion. The core is submitted to the pathologist during surgery for determination of adequacy of the specimen. The pathologist examines the specimen and carries out a cytological touch prep, says Stainton. The results of the pathologists consult indicate whether the core contains sufficient tissue for diagnosis or if another core is needed. Later, the pathologist examines the core biopsy for diagnosis.

Use 88329 for the consultation during surgery and 88161 for the touch prep. Also, report the surgical pathology evaluation service for the biopsy. Although the lung needle core biopsy is not a listed specimen, the work involved would be similar to 88305 (Level IV surgical pathology, gross and microscopic examination; lung, transbronchial biopsy).

Key Features Summary

Remembering the key features of the codes for pathology consultation during surgery will help you code correctly for these services:

Use 88331 and 88332 for the same specimen.
88331 describes evaluation of frozen sections cut from the first block of that specimen. Code 88332 describes evaluation of frozen sections cut from the second block of the same specimen (and an additional unit of 88332 for any subsequent blocks from the same specimen).

In addition, code separately for other services pathologists provide, such