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Pathology/Lab Coding Alert

Thyroid Basics:

Here's How to Report the Pathology Exams

Published on Mon Sep 27, 2004

It all comes down to separate specimens, experts say

One lobe or two? The answer may surprise you - and that's just the first question that complicates thyroid coding.

Study the following six guidelines to make sure you're getting all the payment you deserve when your pathologist examines thyroid specimens and associated tissues.

1. Timing Is Everything for Thyroid Lobes

When your pathologist examines both thyroid lobes, should you report one or two units of CPT 88307 (Level V - Surgical pathology, gross and microscopic examination; thyroid, total/lobe)? That depends, says Pamela Younes, MHS, HTL(ASCP), CPC, assistant professor at Baylor College of Medicine in Houston. "If the surgeon performs a total thyroidectomy and submits the entire thyroid for pathological examination, you should report 88307 for the specimen," she says. But surgeons often remove only one lobe, and the pathologist should also report 88307 for examining a single thyroid lobe.

Sometimes the surgeon performs a hemithyroidectomy, and then based on intraoperative findings, separately removes and submits the remaining thyroid lobe in the same operative session. "When the pathologist separately receives and examines the left and right thyroid lobes, you should report two units of 88307," Younes says.

Red flag: You'll need to follow your payer's convention to indicate that you've performed two distinct services, such as reporting 88307 x 2 or listing the second code with modifier -59 (Distinct procedural service).

Some experts caution that you shouldn't always separately report two hemithyroidectomies. If the pathology report treats the two lobes as one specimen and provides one diagnosis, you should not distinguish the lobes for coding purposes. You should only report a separate code if the pathology report shows the work.

2. Biopsy Unlisted? Report It Anyway

Pathologists sometimes receive thyroid biopsy specimens - such as a needle-core biopsy, excisional biopsy, or a thyroid nodule. But "thyroid biopsy" is not among the 185 listed specimens under CPT surgical pathology codes 88302-88309.

CPT instruction for surgical pathology states that "Any unlisted specimen should be assigned to the code which most closely reflects the physician work involved ..." Younes says that means you should assign thyroid biopsy to 88305 (Level IV - Surgical pathology, gross and microscopic examination). Code 88305 commonly describes biopsies, with over half the listed 88305 specimens representing various tissue biopsy samples.

3. Capture FNA Steps

Physicians often use fine needle aspiration (FNA) rather than biopsy to assist in thyroid diagnosis.

Report thyroid FNA just as you'd report any other FNA: Bill for each step that your pathologist carries out. Look for documentation of any of the following steps that your pathologist might perform:

  •  FNA procurement - 10021 (Fine needle aspiration; without imaging guidance). "Report this only if the pathologist extracts the cells," says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

  •  Specimen adequacy check - 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]). "List this code when the pathologist checks an FNA specimen to ensure the presence of adequate diagnostic material," Slagle says.

  •  Specimen examination - 88173 (... interpretation and report).

  •  Cell block - 88305 (... cell block, any source). "Report this code when the pathologist examines a cell block prepared from the FNA specimen," Slagle says.

    4. Watch for Parathyroid Glands

    When performing a thyroidectomy, surgeons typically leave parathyroid glands intact unless indications exist for their removal. If the surgeon separately submits one or more parathyroid glands for pathological examination, you should report each parathyroid examination as 88305 (... parathyroid gland).

    Best strategy: But what if the parathyroid is incidental to the thyroidectomy? Experts differ on this point. "If the pathologist identifies, examines and diagnoses both parathyroid and thyroid glands, you can separately report both services," Slagle says. In other words, if the pathology report shows the work - report the code.

    Younes takes a more conservative approach. "Sometimes we'll receive an intraparenchymal parathyroid or one that is otherwise intimately associated with the thyroid specimen," she says. "In these cases, if the surgeon has not separately identified the parathyroid and the gland does not demonstrate any significant pathology, we do not bill 88305 for the parathyroid in addition to the thyroidectomy 88307."

    5. Code Regional Lymph Nodes Separately

    Although CPT bundles lymph nodes with some surgical pathology specimens such as mastectomy (88309, Level VI - Surgical pathology, gross and microscopic examination; breast, mastectomy - with regional lymph nodes), thyroid is not one of them.

    "Lymph nodes are not typically part of a thyroid specimen, so if the surgeon performs a regional lymph node resection in addition to the thyroidectomy, you should report it separately," Younes says. Report the lymph nodes as 88307 (... lymph nodes, regional resection).

    6. Thyroglossal Duct Stands Alone

    When your pathologist examines a thyroglossal duct cyst, thyroid tissue may be present in the specimen - but you shouldn't report it separately.

     "The thyroglossal duct is the thyroid gland's migration path during fetal development, and it usually closes entirely," Younes says.

    If the duct remains open, collecting fluid and forming a cyst that the surgeon removes, the specimen may contain remnants of thyroid tissue. "Regardless of the presence or absence of thyroid tissue in the cyst, the correct code for the pathologist's examination of a thyroglossal duct cyst is 88305 (... thyroglossal duct/brachial cleft cyst)," Younes says.

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