Pathology/Lab Coding Alert

Answer 3 questions to pick the right code every time  What's your pathologist examining -- cervix or endometrium, conization or curetting, neoplasm or prolapse? The choices are numerous and so are the chances to pick the wrong code. That can cost you money -- so use the following queries to help you pick the proper surgical pathology level for uterine tissue. 1. What Part of the Uterus Is It? Even excluding fallopian tubes, ovaries and vagina, CPT lists as a specimen six -parts- or growths of the uterus that your pathologist might receive: cervix, endocervix, endometrium, uterus, polyp or leiomyoma. Finding the name of the tissue and linking it to a CPT listed specimen is the first step to finding the right code.
 
Pitfall: But that's not always easy because the surgeon or pathologist might use a different term than CPT, says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., a pathology business practices publishing company in Simpsonville, Ky. 
 
For instance, other terms that might appear in the report that mean the same thing as leiomyoma include fibroid, fibromyoma, myoma or leiomyofibroma. -If you see any of these names and the pathologist did not examine the entire uterus but just looked at the excised leiomyoma, you should code 88305 [Level IV -- Surgical pathology, gross and microscopic examination, leiomyoma(s), uterine myomectomy -- without uterus],- Padget says.
 
Don't miss: You might find uterine specimens in the pathology report that are not listed in CPT, such as cervical cyst. That's when you-ll have to select the code based on the level of work for a comparable specimen. For instance, coding for a cervical cyst is similar to a cervical biopsy (88305), Padget says.
 
See Clip-and-Save Chart: Match Pathology Report Keywords to Uterus Codes on page 59 to help you identify keywords, synonyms or unlisted specimens you might see that will help you correlate the pathology report to listed CPT uterine specimens.
 
But even identifying the tissue type won't necessarily lead you to the proper code. After all, CPT lists uterus, with or without tubes and ovaries, under 88305, 88307 and 88309. That's why you also have to answer the following questions to pick the proper code: 2. What Type of Procedure Did the Surgeon Carry Out? Once you-ve identified the part -- such as cervix or endometrium -- the next step to selecting the correct code is understanding the type of extraction the surgeon performed.
 
Watch for: The surgeon might carry out a hysterectomy, resecting the entire uterus with or without fallopian tubes and ovaries. Or the surgeon might [...]