Pathology/Lab Coding Alert

Don’t forget to add the date when you create a documentation addendum.

Every coding professional knows that documentation is paramount if you want to collect from insurers. Not only does thorough documentation allow you to select the most accurate codes — it also helps support your claims if an auditor comes calling.

Anyone reviewing your pathology claims would want to ensure that every detail in the documentation justifies the codes you report and demonstrates medical necessary for the services you bill to payers. No matter which insurers you bill most often, ironclad documentation will be essential to keeping your pathology practice’s pay flowing.

Check out these three tips that can help your lab create compliant documentation every time.

1. Ensure That Your Documentation Is Precise and Complete

Every piece of documentation that your lab produces — whether it’s paper or electronic — must support the rationale for the diagnosis and the medical necessity for the procedure. If it doesn’t, you should question the reliability of the note and ask the pathologist for clarification.

Most denials occur when at least part of the documentation doesn’t support the codes you report, and that may stem from incomplete or imprecise documentation.

Good documentation fully addresses all necessary items, including complete patient information, a procedure description, a diagnosis statement, and provider identification. It should also use precise terminology, such as using “biopsy” to refer to specimens that do not involve margin exams. This will help you code accurately and will allow auditors to match procedure notes to the codes you submit.

If you don’t document thoroughly and precisely, you may end up being unable to justify higher-paying codes.

Example: The surgeon submits a sample marked “breast lesion excision, upper inner quadrant,” from a patient with a prior biopsy diagnosis of ductal carcinoma in situ (DCIS). The pathologist documents examining the specimen using hematoxylin and eosin (H&E) stained slides and documents a diagnosis of “infiltrating ductal carcinoma.”

Solution: As documented, you should use 88305 (Level IV, Surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins…) for the pathologist’s specimen exam. Although the surgeon submitted a lesion excision, the pathologist did not document a margin exam, so you cannot accurately code the case with 88307 (Level V, Surgical pathology, gross and microscopic examination, breast, excision of lesion, requiring microscopic evaluation of surgical margins). If the pathologist had added “margins clear” to the diagnosis statement, this case would earn 88307, which pays $213 more than 88305, according to the 2024 Medicare Physician Fee Schedule national amount.

2. Ensure That Documentation Takes Place Swiftly

It’s essential that your pathologist completes their documentation either during or immediately after an encounter or lab service.

Here’s why: Only the pieces and parts of a specific service may get documented if too much time has passed and the pathologist can’t remember all of the details — details that may be the difference between identifying a correctly documented service and one that doesn’t support the service billed. Practices should avoid having to defend the provider’s memory, which is why it’s essential to complete the documentation as soon as possible.

Tip 3: Be Diligent When Updating Documentation

When necessary, your pathologist can go back and add an addendum to the record to correct/add additional information, but you must stay within the regulations of your payer, state laws, hospital rules, and your own compliance program to do this. In addition, you must ensure that the pathologist isn’t amending the record just to get the claim paid.

When amending a medical record, you must do so in a way that allows any subsequent treating provider reviewing the patient’s medical record to determine precisely what the amendment is and when it was made. That means providers should initial or sign an addendum, and include the date and time they made the revision. Whoever performed the service should personally make the change to the record — the signature and date can’t be added by a representative or the coder.

Avoid: You should never consider whether the patient has coverage when making your decision on how to treat the patient, and you can’t change the record to reflect information that will help get the claim paid if it’s not true to what the doctor performed.

Follow these five steps to make sure your corrections will pass a review:

1. If you are correcting an incorrect statement in the record, you should draw a line through the statement and put the word “error” next to it. Then sign or initial it (depending on your policy) and put the date. The original information must still be readable and included in the record. Use just a single line to cross it out.

2. Never try to make a late entry appear like it was there all along. Be sure to clearly mark the correction or supplementation as a late entry with a title, such as “Addendum to the medical record made on March 5, 2024, by Steve Smith, MD.”

3. Any late entry should include its date. Additionally, corrections or additions to documentation should ideally be made by the documentation’s original author. That person should sign the correction as well as date it.

4. Always record the purpose of the entry. It’s also helpful to indicate the source of the additional information, such as “based on notes jotted during the visit” or “addended note after listening to dictated report.”

5. If you make a correction in the electronic health record (EHR) and there was also a hard copy printed from the electronic record, you must also correct or reprint the hard copy.

Tip: Always review your payers’ rules on addenda, especially federal health programs like Medicare and Medicaid.

Torrey Kim, Contributing Writer, Raleigh, N.C.