Wiki CYTOLOGY

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This is the entire report. What CPT code would you use?

Final Diagnosis

Synovial fluid analysis with regards to requisition _____________________

Knee, left, synovial fluid analysis:
-Acute and chronic inflammation
-Rare debris identified
-No crystals identified

Specimen adequacy: Satisfactory.
 
In my opinion, there is nothing codeable (CPT assignment from this). What was the cytopreparation performed?
I'm guessing you are a possibly a coder assigned to code procedures from a facility utilizing PowerPath. The information you need is in the specimen tab that isn't provided to you. This is a complete mess in my opinion. I would query the pathologist and ask what actually happened and ask them to do an addendum and "add the necessary information to make this coding scenario compliant" in the actual pathology report. (Information not part of the medical record, such as a pathology report, isn't documented even if it is another system within a healthcare facility). It truly isn't part of the patient's medical record. If audited - what is the facility going to provide?? I already see your "knee, left, synovial analysis, but what was done? I am betting it's 88112 or 88108, but I would query the pathologist; They can add "smart texts" like they do in the Epic world or configure PowerPath to add information "smart phrases" where they can document information and it carries over to EPIC.
I am hopeful your coding woes will decrease and have a great evening,
Dana Chock
 
In my opinion, there is nothing codeable (CPT assignment from this). What was the cytopreparation performed?
I'm guessing you are a possibly a coder assigned to code procedures from a facility utilizing PowerPath. The information you need is in the specimen tab that isn't provided to you. This is a complete mess in my opinion. I would query the pathologist and ask what actually happened and ask them to do an addendum and "add the necessary information to make this coding scenario compliant" in the actual pathology report. (Information not part of the medical record, such as a pathology report, isn't documented even if it is another system within a healthcare facility). It truly isn't part of the patient's medical record. If audited - what is the facility going to provide?? I already see your "knee, left, synovial analysis, but what was done? I am betting it's 88112 or 88108, but I would query the pathologist; They can add "smart texts" like they do in the Epic world or configure PowerPath to add information "smart phrases" where they can document information and it carries over to EPIC.
I am hopeful your coding woes will decrease and have a great evening,
Dana Chock
Thank you for your response! This is exactly what I have been telling them! So here is another issue...how would you code this?

Final Diagnosis

CBC review with regards to requisition ________________

Final Impression:
-Leukopenia with absolute monocytosis and absolute neutopenia
-Macrocytic anemia
-Thrombocytopenia
-Nucleated red blood cell identified
-No blast or blast equivalent cells identified

Comment: The above specimen (purple top tube) has been sent for flow cytometry.

Specimen adequacy: Satisfactory

They are telling me this is a peripheral smear, 85060.
 

brandyb82104@gmail.com

If you really want my opinion, nothing happened per this report, and I'll explain why. Okay let's review this one together. The pathologist reviews the CBC and references the requisition and in "my complete opinion" talks about the CBC and then goes on to "comment' to state that "The above specimen (purple top tube) has been sent for flow cytometry. Therefore, were their multiple tubes provided? No way of telling from the documentation.
What was performed to support billing an 85060 procedure? Per your documentation nothing simply happened. I am actually in a new role as a CQA (coding, quality analysis) role solely in pathology and still review denials for pathology for a different company "casually", but this would clearly not suffice in my complete opinion for any type of audit such as a RAC or just simply sending the pathology report to support billing this charge for any type of appeal.
I do not know what type of system is being utilized or the LIS (transferring information from one place to another) system this is, but whatever is being utilized as the pathology platform is not sending the necessary information to support billing this charge. They need to create ~ what do they call it possibly "smart texts" in EPIC, but I know other applications like PowerPath and some other pathology programs can create those same type of "smart texts" to add notes to explain what was exactly performed and their results. It may simply be an information transferring issue and having the pathologist add a few "quick smart phrases" to send on the LIS to the coding platform.
The specimen adequacy: satisfactory; again, reviewing the pathology report it is almost like they (pathologist) are discussing the CBC (no one knows - it doesn't state)?
No, this (again in my opinion) is not adequate for any type of 85060 charge. Normally, I would see a chart or if not for those facilities (that can't) a resemblance of a chart listing all those necessary percentages - rows stacked up "neatly" on the left side of the pathology report was performed along with the final interpretation.
I am hopeful, I gave adequate feedback on this scenario.
Please don't be worried to reach out and ask for help. I want you to succeed in your pathology role. You are doing a fantastic job questioning coding issue(s); Please continue doing so - you will be a fantastic pathology coder that everyone wants! (PS - personal experience, there is a demand for those rare "pathology" coders; I just found my forever career in April).
Have a fantastic evening!
Dana
 
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