Pathology/Lab Coding Alert

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You receive a gastrectomy pathology report that includes a laundry list of tissues and diagnoses--how can you be sure you code properly and avoid leaving money on the table?

Use what you learned from "Take 3 Steps to Perfect Gastrectomy Coding Every Time" on the cover and try to code the following abbreviated case:

Tissue submitted: Liver biopsy, gastrectomy, skin excision

Gross description:

A. Liver: Specimen is a 1-cm red piece of firm tissue sectioned and submitted.

B. Gastrectomy: Specimen received fresh and consists of stomach, omentum and attached spleen. On external examination, no masses identified in stomach or omentum. Stomach opened and serially sectioned. An ulcerated tumor with raised borders is identified on the greater curvature measuring 2 cm in diameter. The ulcer is sectioned and does not appear to penetrate the gastric serosa. The omentum is sectioned, and 23 lymph nodes are identified and submitted. The spleen is sectioned and representative sections submitted with no tumors identified.

C. Skin: Specimen is an ellipse of skin, sectioned by multiple knife cuts and identified as a dermal scar. Sections are submitted.

Diagnosis:

Liver biopsy: negative for tumor
Gastrectomy specimen: adenocarcinoma 
23 lymph nodes: no evidence of metastatic tumor no tumor identified in omentum
Spleen: negative for tumor
Skin: Scar Code the Case, Then Check Your Answers Here:

Although the gross description states that the specimen "consists of stomach, omentum and attached spleen," you can see that the pathologist individually examined and diagnosed the spleen. "You should code for the spleen as a separate specimen," says R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services, an independent pathology laboratory in Jonesboro, Ark. On the other hand, you should bundle the omentum lymph nodes with the stomach based on coding conventions for Level VI surgical pathology specimens.

Code the case as follows:

• CPT 88307 --Level V--Surgical pathology, gross and microscopic examination, liver, biopsy--needle/wedge

• 88309--Level VI--Surgical pathology, gross and microscopic examination, stomach--subtotal/total resection for tumor

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

• 88302--Level II--Surgical pathology, gross and microscopic examination, skin, plastic repair.