Pathology/Lab Coding Alert

When surgical pathologists provide multiple margin-evaluation services for neoplasm, you need to capture each procedure for payment. Reporting a lower surgical pathology level or failing to report adjunct services could mean sacrificing legitimate payment.

"Not only can margin evaluation increase the surgical pathology examination level, it can also involve additional procedures," says R.M. Stainton, MD, president of Doctor's Anatomic Pathology in Jonesboro, Ark., which serves 12 hospitals and numerous physician offices in Arkansas and Missouri.

Surgical pathology services (88300-88309) involve gross and microscopic (except 88300) examination of a surgically removed tissue specimen. The codes represent ascending levels of work, and CPT may list the same tissue under multiple codes based on the extent of examination work involved. Factors such as the suspicion of neoplasm, and the need to evaluate surgical margins, affect the code selection for many tissues. Margins Impact Surgical Pathology Level When the pathologist evaluates margins, the service sometimes warrants a higher surgical pathology level because the specimen may be neoplastic. "Margins aren't the reason for coding the higher level, but when coders see notes about margin evaluation in the pathology report, it should be a clue that the specimen is being evaluated for tumor," Stainton says. The notes may refer to "inked margins" and provide specific information, such as distance of tumor cells from the margin.

Breast tissue codes specifically differentiate whether the specimen requires margin evaluation: 88305 (Level IV - Surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins) and CPT 88307 (Level V - Surgical pathology, gross and microscopic examination, breast, excision of lesion, requiring microscopic evaluation of surgical margins).

Margin evaluation is also a factor when assigning the proper code level for other tissues that use terminology such as "neoplastic" or "for tumor." For example, stomach resection for tumor involves margin evaluation and is assigned a higher level (88309, Level VI - Surgical pathology, gross and microscopic examination, stomach - subtotal/total resection for tumor) than stomach resection for other causes (88307, & stomach - subtotal/total resection, other than for tumor). Similarly, colon resection for tumor requires margin evaluation (88309, & colon, segmental resection for tumor), while resection for conditions such as diverticulosis does not (88307, & colon, segmental resection, other than for tumor). Skin specimens also require margin evaluation only at the highest level of service, such as for squamous cell carcinoma or other neoplasms (88305, & skin, other than cyst/tag/debridement/plastic repair). Evaluation of breast tissue provides some sticky coding scenarios involving margins. For example, the surgeon may perform a lumpectomy and, upon gross findings of tumor near the margin, sample additional margins. The pathologist receives a lumpectomy and three margins labeled anterior, superior and lateral. "Report this service as 88307 (& [...]