Pathology/Lab Coding Alert

When your pathologist diagnoses "giant cell tumor of tendon sheath," do you code 88304 or 88307? The wrong choice could cost you $112.

Tendon sheath is a listed specimen under 88304 (Level III -- Surgical pathology, gross and microscopic examination, tendon/tendon sheath).

But most pathologists will tell you that a "giant cell tumor of tendon sheath" specimen is more akin to a soft tissue mass than to a piece of tendon sheath -- which points to 88307 (Level V -- Surgical pathology, gross and microscopic examination, soft-tissue mass [except lipoma] -quot; biopsy/simple excision), according to Stephen Yurco III, MD, partner and pathologist at Clinical Pathology Associates in Austin, Texas.

Problem: CPT rules state that the "assigned specimens" define the surgical pathology code level -- you cannot select a higher code level based on physician work. Only unlisted specimens warrant selecting the surgical pathology level based on "the code which most closely reflects the physician work involved when compared to other specimens assigned to that code."

What's in a name? "If your pathology report identifies -tendon sheath- but never mentions -soft tissue mass,- you-ll have a hard time justifying 88307 when a payer or auditor looks at your claim," Yurco says.

ICD-9 compounds confusion: You won't find much help in the ICD-9 code for the condition -- 727.02 (Giant cell tumor of tendon sheath). The code is under category 727.x (Other disorders of synovium, tendon and bursa), which doesn't provide much support for a "soft tissue mass" specimen.

Don't select ICD-9 for payment: If the word "tumor" encouraged you to begin your ICD-9 search for giant cell tumor of tendon sheath in the neoplasm table, you might end up selecting 215.x (Other benign neoplasm of connective and other soft tissue), which ICD-9 states, "includes tendon (sheath)."

But you would be wrong, because ICD-9 provides a more specific code for the condition -- 727.02 -- which is not a neoplasm. You shouldn't use 215.x just because you think it provides better justification for an 88307 "soft tissue mass" specimen charge.

Given these CPT and ICD-9 code indicators, how can you know that a giant cell tumor of tendon sheath constitutes a soft-tissue mass specimen?

"This is one of those situations where you just have to know what the right answer is, because you can't readily get there by the usual CPT/ICD-9 reference process," says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., a pathology business practices company in Simpsonville, Ky. "The term -tendon sheath- in the specimen label is misleading, because the only relationship of -giant cell tumor- to tendon sheath is physical proximity -- it often arises in the soft tissue around the tendon sheath. But it's definitely a soft-tissue condition, not a problem with the tendon sheath."

"We always see this type of tumor invading soft tissue -- it is not a tendon-sheath specimen," Yurco says.

The AMA confirms that giant cell tumor of tendon sheath is a soft-tissue mass, according to the latest update of Pathology Service Coding Handbook version 8.1, by Dennis Padget.

Now that you know the score, what can you do to show your payers and auditors that your 88307 claim for giant cell tumor of tendon sheath is legitimate?

Follow these four tips to ensure that your documentation supports a "soft-tissue mass" 88307 claim:

1. Use the pathology report -- not the surgeon's specimen description -- to support your claim.

2. You can't avoid the appropriate diagnosis -- giant cell tumor of tendon sheath -- just because it's confusing. But educate pathologists that they should use keywords such as "soft-tissue mass" and "biopsy" or "excision" to help coders, payers and auditors avoid confusion about the proper procedure code selection.

"For instance, the pathology report gross description might state, -Specimen is 1.3-cm-by-3.5-cm soft-tissue mass excised from the left thumb,- " Padget says.

3. Make sure you don't have a lipoma. If the pathologist documents a fatty tumor in the soft tissue, you-ll have to report 88304 (- soft tissue, lipoma) instead of 88307 for other soft-tissue masses.

4. Make sure you don't have a tendon sheath. If the pathologist documents that the specimen is a tendon sheath -- a tubular tissue that surrounds and lubricates some tendons -- you-ll have to report 88304.

Don't miss: Getting the 88304/88307 distinction right could put an extra $112 in your pocket -- based on the Physician Fee Schedule nonfacility total using Medicare's updated conversion factor for Jan. 1 to July 1, 2008.