Pathology/Lab Coding Alert

Question: Can we bill for special stains when the pathologist states that the stain was "non-contributory?" For example, if a pathologist orders two immunoperoxidase stains for solid-tumor markers and only one is positive and the other is normal, should we code for both stains? Similarly, if the pathologist examines a liver biopsy trichrome stain and finds no abnormal cells in the biopsy specimen, can we bill for the service?
Massachusetts Subscriber


Answer: You should report every stain that the pathologist performs and lists in the pathology report, regardless of whether the stain "contributes" to the diagnosis. Only if the pathologist has nothing to examine, such as when he receives insufficient tissue or cells, should you not report the service.
 
For example, if the pathologist examined two immunoperoxidase stains for a gastric tumor, finding the tissue S-100 positive and CD 34 negative, you should report 88342 x 2 (Immunocytochemistry [including tissue immunoperoxidase], each antibody) even though one result was positive. Similarly, you should use +CPT 88313 (Special stains [list separately in addition to code for surgical pathology examination]; Group II, all other [e.g., iron, trichrome], except immunocytochemistry and immunoperoxidase stains, each) if the pathologist examines a liver biopsy trichrome stain, regardless of the findings.
 
Advise your pathologist to avoid terms in the report that could be construed as not indicating medical necessity, such as "non-contributory," "normal," or "non-diagnostic." Instead, use terminology that indicates the work completed, such as "tissue negative for CD 34 stain," or "abnormal cells not established on trichrome stain."