Pathology/Lab Coding Alert

Understanding when tissue samples represent different specimens is the key to correct coding for surgical pathology. But lab personnel say they often find the definition confusing. Just because specimens arrive in different containers, should they be considered separate? Should tissue from different organs always be considered separate specimens?

Its crucial to answer these questions correctly in order to receive fair reimbursement for services provided. Improperly separating tissue into different specimens is considered unbundling, which is the incorrect practice of breaking down a single procedure into its component parts, and billing for additional services. Unbundling can result in denial of a claim, or even charges of fraud. On the other hand, grouping samples together that could be properly identified as separate specimens results in underpayment of claims.

Some guidelines are clearly laid out in the code, says Debbie Siena, HT (ASCP), manager of the histology department of Baylor University Medical Center in Dallas, Texas. For example, because code 88309 reads breast, mastectomywith regional lymph nodes, it would be the only code used for examination of tissue from a modified radical mastectomy. It would not be appropriate to separately code the axillary lymph nodes from this procedure as CPT 88307 (lymph nodes, regional resection). There are a number of other tissues that are specifically grouped in this way, according to Siena, for example uterus with tubes and ovaries (88305-88309), larynx with regional lymph nodes (88309), tonsils with adenoids (88304), multiple hemorrhoids (88304), and multiple fingers or toes from the same hand or foot (88302).

Number of Containers Not Relevant

Part of the confusion stems from tissue samples being submitted to the lab in a manner that is inconsistent with the specimen. For example, a hysterectomy may be performed for uterine leiomyoma (218), but the surgeon may place the incidental tubes and ovaries in a separate container from the uterus. Regardless of the number of containers, 88307 should be reported once because the code specifies uterus, with or without tubes and ovaries.

There are also occasions, however, that the CPT code doesnt specify with or without associated organs, such as the seminal vesicles that are typically removed in a radical resection of the prostate. However, tissues that are normally removed together should be treated as a single unit of service. Unless specifically directed otherwise, these tissues do not require individual examination and pathologic diagnosis, as specified in CPT, so they are considered one specimen. Even if these tissues came to the lab in separate containers, 88309 (prostate, radical resection) should be reported once.

Conversely, separate specimens are sometimes submitted in the same container, and should be coded individually. For example, Two or more separately identified skin lesions should each be assigned the proper level of service (88302-88305) and coded separately, even if they came to the lab in one container, says Siena. However, two skin lesions that are not distinguished in any way would only be coded once.

Understand Clinical History

Clinical history and surgical notes are crucial for knowing how to code a specimen, Siena continues. There are two guidelines that can help. First, if the samples are somehow differentiated with a suture, tag, clamp, or even a surgical note such as the larger of the two lesions ..., then they should be considered two specimens to be examined, diagnosed and coded separately.

The second guideline is to use surgical notes and knowledge of the patients clinical history as the basis of the codes selected. This can sometimes result in legitimately identifying two specimens for tissue that is typically grouped as one.

For example, if an ovary is removed because of a tumor, it is the primary specimen and would be coded 88307 (ovary, neoplastic). If the surgeon also removes the uterus for a separate evaluation for involvement of metastatic disease, it would be coded separately as 88307 (uterus other than neoplastic/prolapse), or 88309 (uterus neoplastic), depending on the findings. Although CPT lists uterus, with or without tubes and ovaries as a single specimen, the intention is to link those tissues only if they are incidental. If clinical history and surgical notes specify the tissue for individual examination and pathologic diagnosis, then two separate codes should be used.

Complex and Radical Surgical Procedures

Multiple organs may be removed in complex and radical surgical procedures. Although they may be attached, each organ requiring separate attention should be coded based on the CPT specimen list for codes 88302-88309. A clinical example might be the radical cystoprostatectomy of the bladder and prostate, which are not ordinarily removed together. Each organ would be coded separately based on the level of service provided. If the disease involved prostatic adenocarcinoma and urothelial carcinoma, 88309 would be coded twice (prostate, radical resection and urinary bladder, partial/total resection). On the other hand, if the condition were urothelial dysplasia extending into the urethra, a more limited examination of the prostate would require a lower code for that portion of the service (88307, prostate, except radical resection).

Be aware that if multiple tissues are removed that do not each require individual evaluation, only those examined separately should be coded. For example, a neck dissection that includes salivary gland, regional lymph nodes, vascular structures and muscle tissue would be coded 88307 twice (lymph nodes, regional resection and salivary gland). The muscle and vascular tissue would not be coded unless a separate evaluation is required due to a condition such as extension of neoplasm into soft tissue.

Avoiding Lymph Nodes Confusion

Coding for lymph node evaluations can be confusing because sometimes they are considered a separate specimen, and sometimes they are not. Clearly, they are not a separate specimen when included in the CPT designation, such as 88309 (larynx, partial/total resectionwith regional lymph nodes, or breast, mastectomywith regional lymph nodes). Other lymph nodes that would not be coded separately, according to published reports of the College of American Pathologists, are those ordinarily attached to a specimen, such as the gallbladder with lymph nodes in a cholecystectomy (88304) or the colon with mesenteric lymph nodes in a colectomy for neoplasm (88309). However, lymph nodes that are not normally part of a specimen, such as the periaortic lymph node with the colon or gallbladder, would be coded separately if submitted.

Multiple regional lymph nodes often are submitted with other specimens for examination to determine the extent of metastatic disease. Since each regional lymph node resection requires a separate dissection and evaluation, they would be reported separately (88307). A sentinel lymph node biopsy is a distinct service apart from a regional lymph node resection. When both services are provided, they are coded separately (88307, lymph nodes, regional resection, and 88305, lymph node, biopsy)