Pathology/Lab Coding Alert

Surgical pathology Coder beware: Knowing the organ or anatomic site is not enough to determine the level of service. Although using 88300-88309 appears simple just find the specimen in the list under each code looks can be deceiving. Coders won't find the specimens indexed in the CPT manual , either.

"Many organs appear under multiple codes for surgical pathology; some even appear at every level of service," says R.M. Stainton, MD, president of Doctor's Anatomic Pathology in Jonesboro, Ark. For example, "testis," with various modifying terms, is a listed specimen under each of the codes 88302-88309 (Level II through VI Surgical pathology, gross and microscopic examination). "Pathology coders have to understand the many factors that determine the level of service for a particular organ or tissue type," Stainton says. Surgical Pathology Coding Basics The unit of service for surgical pathology codes 88300-88309 is the specimen, which CPT defines as "tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis." The service provided for each specimen is "accession, examination and reporting." Except for 88300 Level I Surgical pathology, gross examination only), the work involves gross and microscopic examination of the tissue, including routine staining such as hematoxylin and eosin (H&E). The codes represent ascending levels of physician work.

A list of specimens follows each surgical pathology code descriptor in the CPT manual. Listed specimens should be assigned to the appropriate code. "Only if the specimen is unlisted should it be assigned to a code based on the physician's determination of the level of work involved," Stainton says.

Pathologists and coders must do their part to ensure accurate coding for surgical pathology services. "The pathologist must provide a diagnosis and description of the specimen or specimens," Stainton explains. "Meanwhile, the coder must understand which of these factors, beyond just the name of the organ or anatomic site, will impact code assignment." Know the Diagnosis Before Coding Many surgical pathology codes rely not just on the type and extent of tissue the pathologist examines but also on the final diagnosis. "Several tissues are assigned to a different level of surgical pathology depending on whether the diagnosis is neoplastic," says Peggy Slagle, CPC, billing compliance coordinator, University of Nebraska Medical Center in Omaha. For example, coders should report a uterus submitted with a clinical diagnosis of endometriosis (617.0) as 88307 ( uterus, with or without tubes and ovaries, other than neoplastic/prolapse) if the pathologist's examination confirms the suspected diagnosis. "However, if the pathologist diagnoses adenocarcinoma of the endometrium [182.0, Malignant neoplasm of the corpus uteri, except isthmus] based on the gross and microscopic examination, the [...]