Pathology/Lab Coding Alert

" When the pathology report uses different language than the code books, you need a translator. Terms like tumor" " "benign " "polyp" and "primary" define the procedure and diagnosis codes for colon specimens but the pathology reports may not contain these exact words.

"We assign the procedure and diagnosis codes for colon specimens based on the pathology report " says Elizabeth Sheppard HT (ASCP) manager of Anatomic Pathology at Wake Forest University Baptist Medical Center in Winston Salem N.C. You must be familiar with the terminology in the medical record whether it's specific histologic nomenclature or morphology of neoplasm codes. You must also be able to translate the terminology into the correct CPT and ICD-9 code for labs that assign diagnosis codes based on the pathologic findings.

"Assigning procedure codes for the colon is straightforward but we don't assign the ICD-9 codes in our practice " says Stephen Yurco III MD partner and pathologist at Clinical Pathology Associates in Austin Texas. "Because the final colon diagnosis is not pertinent to CPT coding except to know whether a partial resection is for a tumor we leave the ICD-9 coding to the clinician who ordered the test." Specimen and Diagnosis Determine Procedure Code "Pathologists report examination of colon tissue using one of four surgical pathology codes " Yurco says. Bill the colon and skin tissue from a colostomy with 88304 (Level III Surgical pathology gross and microscopic examination colon colostomy stoma). For a colon biopsy or polyp report 88305 (Level IV Surgical pathology gross and microscopic examination colon biopsy; or polyp colorectal). "Regardless of the diagnosis pathologists bill 88305 for a colon polyp or biopsy " Yurco says.

"Sometimes surgeons will excise multiple polyps and submit them for diagnosis " Yurco says. "If they are submitted for individual examination based on a surgical note or physical mark to distinguish the specimens it is appropriate to report multiple units of 88305. But be careful to individually list each specimen and the pathologic findings in the pathology report to document multiple specimens."

Report a partial colon resection using one of two different codes depending on whether or not a neoplasm is involved: 88307 (Level V Surgical pathology gross and microscopic examination colon segmental resection other than for tumor) or 88309 (Level VI Surgical pathology gross and microscopic examination colon segmental resection for tumor). Also use 88309 ( colon total resection) to report a total resection regardless of the diagnosis. For the partial resection you should know something about the diagnosis of neoplasm. "If the patient has a confirmed diagnosis of colon tumor based on a previous biopsy for [...]