Follow 3 Tips to Perfect Your Bone Marrow Pathology Exam Coding
Look to this advice to avoid overbilling. Bone marrow cases with multiple specimens and special studies have lots of details to sort out if you want to avoid coding missteps and get all the pay your pathologist deserves. Use the following bone marrow case to track three expert tips that will make your job easier — and ensure clean claims. Study the Pathology Report Patient: 76-year-old male with anemia of chronic kidney disease (CKD) Specimens: A) Bone marrow biopsy B) Bone marrow aspiration smears C) Bone marrow clot D) Blood, peripheral Gross Description: Microscopic Description: Flow Cytometry: Final Diagnosis: Myelodysplastic Syndromes with Ring Sideroblasts (MDS-RS) Tip 1: Code Each Specimen The preceding case identifies four unique specimens. When you consider coding this case for a hospital inpatient, you should report the following to capture the pathology work: Report the bone marrow tissue biopsy pathology exam using 88305 (Level IV - Surgical pathology, gross and microscopic examination … Bone marrow, biopsy). The correct code for the pathology exam of a bone marrow aspiration smears is 85097 (Bone marrow, smear interpretation). Remember: Because bone marrow biopsy and aspiration specimens may provide different diagnostic information for certain conditions, using different methodologies to evaluate both specimens from the same patient on the same day isn’t unusual. Using the bone marrow aspirate, the pathologist may process a clot as a cell block, in addition to the aspirate smeared directly onto microscope slides. If the pathologist documents processing and examining the clot, as they do in this case, you’ll code an additional unit of 88305 (…Cell block, any source ...). The correct code for the interpretation of the peripheral blood smear in this case is 85060 (Blood smear, peripheral, interpretation by physician with written report). Tip 2: Capture Ancillary Procedures Code the decalcification: It’s easy to miss, but the gross description for Specimen A stated, “The specimen is submitted entirely in cassette A1, following decalcification.” In this situation, you need to capture the decalcification step, because if you don’t, you’ll be leaving money on the table. The correct code for decalcification is +88311 (Decalcification procedure (List separately in addition to code for surgical pathology examination)). Because the bone marrow core biopsy is the only specimen decalcified, you’ll list just 1 unit of +88311 for this case. Code the special stain: You can see that the lab also processed two aspirate smears with an iron stain, such as Prussian blue. You should report that service with 88313 (Special stain including interpretation and report; Group II, all other (eg, iron, trichrome), except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry). Because the pathologist evaluates two iron-stain smears, you can report 2 units of 88313, as CPT® instructions state, “Report one unit of 88313 for each special stain, on each surgical pathology block, cytologic specimen, or hematologic smear.” Code the flow: The pathology report documents immunophenotyping of the bone marrow aspirate using flow cytometry. In addition to 27 cluster of differentiation (CD) markers, the flow analysis evaluates HLA-DR, Kappa, and Lambda for a total of 30 cell surface markers. The presence or absence of these markers can help determine maturation, lineage, and function of cells for the evaluation of diseases such as leukemia and lymphoma. Code the flow cytometry evaluation in this case using 88189 (Flow Cytometry, Interpretation; 16 or More Markers) if appropriate. Tip 3: Avoid Overbilling Traps Although the gross description for Specimen B states that two aspirate slides were submitted “with Wright-Giemsa stain,” you should not separately bill those as two more special stain codes. Why? Because Wright-Giemsa is the routine stain for bone marrow aspirate smears, you should not charge separately for the stain. This can be a point of confusion because Wright-Giemsa is separately billable in some situations, such as a gastric biopsy stain for H. pylori. But just as you wouldn’t separately bill the hematoxylin and eosin (H&E) stain that is standard for most pathology tissue specimens, you shouldn’t separately bill the standard Wright-Giemsa for bone marrow aspirate smears. Watch patient status: Another coding pitfall for this case is the patient place of service. Although you can bill 85060 for physician interpretation of the peripheral blood smear in this case, that’s only because the situation involves a hospital inpatient. Medicare assigns code 85060 a professional/technical component (PC/TC) indicator of “8,” stating, “Medicare may make separate payment only if the physician interprets an abnormal smear for a hospital inpatient. This applies only to code 85060. Medicare doesn’t recognize TC billing because we make payment for the underlying clinical laboratory test to the hospital, generally through the Prospective Payment System (PPS) rate. Medicare doesn’t make payment for code 85060 provided to hospital outpatients or non-hospital patients. Medicare pays the physician interpretation through the clinical laboratory fee schedule (CLFS) payment for the clinical laboratory test.” Ellen Garver, BS, BA, Contributing Writer
Medullary bone is present with focal aspiration artifact. Cellularity is approximately 35%. Myeloid to erythroid ratio normal with megakaryocytes present.
The smear is cellular with mild trilineage dysplasia. Myeloid maturation shows maturation arrest. Blasts are less than 5%. Monocytes are increased. Megakaryocytes are present and morphologically unremarkable. Ring sideroblasts are identified, approximately 20%.
The clot contains cellular composition similar to biopsy core.
Red blood cells are decreased with mild anisopoikilocytosis. White blood cells are decreased with absolute monocytosis. Platelets are decreased with frequent large forms and scattered platelet aggregates.
