Pathology/Lab Coding Alert

Make sure you distinguish aspiration specimens -- find out how.

If you don't know needles, margins, and lymph nodes, you could be leaving money on the table for your pathologist's breast cases.

Our experts help you break down breast coding into four easy steps. Follow these guidelines to capture all your breast pathology pay.

1. Define Needle Specimen

Surgeons sometimes take needle extractions from breast lesions. To get the code right, you-ll need to understand the different specimens and procedures your pathologist might encounter for these needle samples.

Cyst puncture aspiration: -If the surgeon uses a needle to withdraw fluid from a breast cyst, your pathologist will examine a cytology specimen,- explains Melanie Witt, RN, CPC-OBGYN, MA, a coding expert based out of Guadalupita, N.M. That means you-ll choose a code from the following list:

- 88104 -- Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation
- 88106 -- - simple filter method with interpretation
- 88107 -- - smears and simple filter preparation with interpretation
- 88108 -- Cytopathology, concentration technique, smears and interpretation (e.g., Saccomanno technique)
- 88112 -- Cytopathology, selective cellular enhancement technique with interpretation (e.g., liquid based slide preparation method), except cervical or vaginal.

Your pathologist will be looking at cells from a fluid specimen, and you should choose one of the above codes based on the lab method used to prepare the slides.

FNA: If the surgeon uses a -fine- needle to -aspirate- cells from a solid breast tumor, the specimen is a -fine needle aspiration- (FNA). Although an FNA specimen is cellular, and thus a cytology specimen, CPT provides different codes for FNA than for cytology specimens described by 88104-88112.

You should report the pathologist's diagnosis of the FNA specimen as 88173 (Cytopathology, evaluation of fine needle aspirate; interpretation and report). Although the lab might prepare the FNA slides by various methods described by 88104-88112, such as direct smear or concentrated smear, you should not report one of these codes in addition to 88173 for the FNA specimen. -Code 88173 includes interpretation of all slides examined from the aspirate regardless of slide preparation method,- Witt cautions.

Pitfall: The cytology specimen from an FNA and a cyst aspiration may look the same, and the pathologist may process it the same (as direct or concentrated smears), so distinguishing the two services may be difficult.

Tip: -We use the surgical code to guide our selection of the specimen type,- says R.M. Stainton Jr., MD, president of Doctors- Anatomic Pathology Services in Jonesboro, Ark. If the surgeon performs 19000 (Puncture aspiration of cyst of breast), select the proper cytology code (88104-88112). If the surgeon performs 10021 (Fine needle aspiration; without imaging guidance) or 10022 (- with imaging guidance), select 88173 for the pathology exam.

Don't miss adequacy check: If the pathologist examines an FNA specimen during surgery, not for diagnosis but solely to determine if the surgeon extracted an adequate specimen, you should report 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]).

-You can report 88172 and 88173 together for the same specimen if the pathologist first determines that the specimen is adequate, then later examines the specimen and provides an interpretation and report,- Stainton says.

Core needle biopsy: The surgeon may use a large-bore needle to extract a -core- or -plug- of tissue from a breast lesion. Unlike the cyst aspiration and FNA, the specimen is tissue, not cells, so you should not use cytology codes. Instead, you should report the pathologist's specimen examination as 88305 (Level IV --" Surgical pathology, gross and microscopic examination; breast, biopsy, not requiring microscopic evaluation of surgical margins). -Don't let the needle confuse you -- this is a tissue biopsy specimen,- Stainton emphasizes.

2. Watch for Margins

You-ve seen one code for breast biopsy -- 88305. But that's not the only code you need to know. Pathologists may examine many configurations of breast tissue, and one distinguishing feature is whether the specimen involves evaluation of the surgical margins.

No margins: If the surgeon removes a portion of a breast mass for diagnostic purposes, you have a biopsy specimen. Because the physicians know that part of the lesion remains in the breast, the pathologist does not evaluate the surgical margins to ensure that they are clear of cancer. Although the surgeon may remove the biopsy using traditional surgical methods, you should code the specimen the same as the core needle biopsy described earlier -- 88305.

Excision requires margin evaluation: If the surgeon removes the entire lesion, you have an excision, not a biopsy specimen. The difference is that the pathologist must examine the surgical margins to ensure that they are clear of cancer. You should code these cases as 88307 (Level V --" Surgical pathology, gross and microscopic examination; breast, excision of lesion, requiring microscopic evaluation of surgical margins). Don't miss: -Lumpectomy- is another common name for this specimen.

Many names earn 88307: Surgeons may remove breast tissue in many configurations under many names, and as a coder, you might find the terminology confusing. CPT provides a couple of these terms under a different specimen listed as 88307 (- breast, mastectomy --" partial/simple). This code describes a partial or total removal of the breast without contiguous lymph nodes. In addition to partial or simple mastectomy, you might see this specimen called -quadrantectomy,- -tylectomy,- or -segmentectomy.-

Caution: -Regardless of what the surgeon calls the breast specimen, you can't report 88307 unless the pathology report documents margin evaluation,- Stainton says.

3. Don't Miss Lymph Nodes

You still need to know one more code for breast specimens -- 88309 (Level VI --" Surgical pathology, gross and microscopic examination; breast, mastectomy --" with regional lymph nodes).-As you can see from the code definition, this specimen involves the entire breast and associated regional lymph nodes,- Witt says. You might see an 88309 breast specimen called a -modified radical mastectomy,- a -simple mastectomy with axillary dissection,- or a -radical mastectomy.-

Watch for separate specimens: Sometimes the surgeon will perform a partial mastectomy and a distinct regional lymph node resection. In that case, you should not report 88309 because the specimen does not involve a total mastectomy. Instead, you should list two separate specimens. You should code 88307 for the partial mastectomy, and another unit of 88307 (- lymph nodes, regional resection) for the lymphadenectomy.

4. Capture Ancillary Services

Pathologists often perform special testing on breast tissue to help identify tumor characteristics that indicate appropriate treatment regimes. You-ll need to know how to code these typical -add-on- services for breast malignancies.

The pathologist may perform analysis of estrogen receptor (ER), progesterone receptor (PR), and Her-2/neu tumor status using immunohistochemistry (IHC) techniques. CPT provides three codes that you might use for any one of these tests, depending on whether the lab performs an analysis that is qualitative, semi-quantitative, or quantitative, and whether the technique is manual or automated. To describe these common breast cancer tests, you should know the following three codes:

- 88342 -- Immunohistochemistry (including tissue immunoperoxidase), each antibody
- 88360 -- Morphometric analysis, tumor immunohistochemistry (e.g., Her-2/neu, estrogen receptor/ progesterone receptor), quantitative or semiquantitative, each antibody; manual
- 88361 -- - using computer-assisted technology.

Code per antibody: -Because the code definitions for 88342 and 88360-88361 designate -per antibody,- each of the tests for ER, PR and Her-2/neu warrants a separate code,- Witt says.

For instance: If the pathologist performs quantitative ER/PR, Her-2/neu breast tumor analysis using an automated platform, you should code 88361 x 3