Pathology/Lab Coding Alert

Document work, specimen description to assign proper 88300-88309 Just because your pathologist doesn't receive enough tissue to make a definitive diagnosis doesn't mean you can't charge for the work he does. An "insufficient" or "inadequate" tissue specimen means you don't get paid if the pathologist doesn't perform a surgical pathology service. But you can get paid if the pathologist documents his work and specimen findings - even if the specimen is non-diagnostic.

Use the following three steps to decode your pathology report and determine if you can charge for those rare cases when the pathologist examines a non-diagnostic specimen. Also use these steps to educate your pathologists about how their documentation can make a difference between payment and "no charge." 1. Recognize the Work A surgical pathology exam includes accession, examination, and report. If you're missing any of these parts, you can't charge for a surgical pathology exam. The code definitions are as follows:

 CPT 88300 , Level I - Surgical pathology, gross examination only

 88302, Level II- Surgical pathology, gross and microscopic examination

 88304, Level III- Surgical pathology, gross and microscopic examination

 88305, Level IV- Surgical pathology, gross and microscopic examination

 88307, Level V- Surgical pathology, gross and microscopic examination

 88309, Level VI- Surgical pathology, gross and microscopic examination. Watch for: The pathology exam must include a gross tissue description and evidence that the pathologist performed a microscopic exam (for 88302-88309). "If the lab accessions a labeled jar that is empty, you can't bill for the requested service," says Pamela Younes, MHS, HTL(ASCP), CPC, assistant professor at Baylor College of Medicine in Houston. Sometimes you'll see a gross tissue description but no findings from a microscopic exam.

For instance, if the pathology report includes a gross description of a very small specimen, but the tissue did not survive processing so that there are no results from a microscopic exam, you can only charge for the gross exam (88300).

Do this: The pathology report should document the work with terms such as "specimen processed and examined." Alternatively, the gross and microscopic description sections of the pathology report should demonstrate work by using descriptors such as "specimen measured ...," "sections exhibited ...," "one slide shows ...," or similar references to the pathologist's work.

2. Identify What You Have, Not What You Don't Have If the pathology report documents the pathologist's gross and microscopic findings, you can charge for the service even if the findings don't provide a definitive diagnosis. On the other hand, if the pathologist simply states that the submitted specimen is "inadequate for evaluation," then you cannot charge for the service. 

Example: When the pathologist's findings don't match the submitted tissue description from the ordering physician, the pathology report should state what is present [...]