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Pathology/Lab Coding Alert

You Be the Coder:

Watch for Add-On Requirements

Published on Thu Apr 23, 2009

Question: Our lab received a toenail biopsy for a fungal exam. We performed a PAS stain rather than a culture and positively identified a fungal infection consistent with onychomycosis. Should we code for the stain only? New Jersey Subscriber Answer: The correct code for the fungal stain on the toenail specimen is +88312 (Special stains [List separately in addition to code for primary service];Group I for microorganisms [e.g., Gridley, acid fast, methenamine silver], each). Because +88312 is an add-on code, however, you have to bill it in addition to the primary service. You don't mention a microscopic exam other than the stain for the toenail specimen. Solution: When the lab accessions the toenail biopsy specimen, at least a gross pathology exam should occur. As long as you have documentation of a pathology gross exam to confirm the specimen, you should report 88300 (Level I -- Surgical pathology, gross examination only). Then [...]
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