Pathology/Lab Coding Alert

Question: Must the pathology report include an interpretation for each special stain before we can bill for it, or is it sufficient if the report simply lists the type and number of stains?

Tennessee Subscriber Answer: Simply listing the type and number of special stains in the pathology report does not provide ample documentation for billing. The pathology report should include the interpretation of each special stain, even if the results are not a factor in the final diagnosis. If the pathologist carries out the stains because they are medically necessary for the diagnosis of the patient's condition, the pathologist must include his interpretation in the report to the ordering physician. Accurate coding and billing also require this sort of documentation.
 
Occasionally the pathologist may find that a stain is nondiagnostic. But the pathology report should still indicate the specific results, such as "Trichrome stain evaluation did not establish abnormal cells." This sort of reporting also provides the specific documentation the coder needs to withstand claims audits.  - Reader Questions and You Be the Coder were prepared with the assistance of R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.