Electrophoresis

Malevolus

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I recently started coding several lab tests - 88334, 88335, 84165, 84166.
Often on the results report there is no diagnosable condition or clinical history listed. I get things like:
"Weak IGG band present in the gamma zone, too weak for electrophoresis"
"No monoclonal immunoglobulins identified by serum immunofixation"
"IGG Kappa band present in the gamma zone in low concentration"
"Homogeneous band (M Spike) present in the gamma zone. Concentration = 0.35g/dl This may be an overestimation due to migration with normal serum proteins. Identified by immunofixation as IGG Kappa"

Now I know I may just be drawing too much on my surgical pathology background and overthinking and being over cautious , or that I'm just not familiar enough with these reports yet. I've talked to another coder and my manager and they suggested looking at abnormal findings codes. Since there is no specific documentation stating abnormal findings, atypical cells, elevated levels, etc, I am uncomfortable coding these as such since I can't confidently back up my coding decisions. I'm looking at it kind of like an intestinal resection for "adenocarcinoma present at 20cm from cecum" This obviously would be the ascending colon, but since it isn't documented as such, and we don't know if the patient has had prior intestinal resections, it would be coded to malignant neoplasm of colon, unspecified site.

I also do not currently have access to the patient's chart. Normally I'd reference the associated visit/Op report/etc and pull a diagnosis from there as to why the test was performed. Would any of you feel confident coding an abnormal finding based off of the interpretations listed above?

Others have interpretations like:
Hypogammaglobulinemia
Homogeneous band (M Spike) present in the gamma zone. Concentration = 0.07g/dl This may be an overestimation due to migration with normal serum proteins. Identified by immunofixation as IGG Kappa

This is pretty straight forward and the Hypogammaglobulinemia is coded. But if you take that away and only have the second part, it goes back to unable to code. I was always lead to believe that you cannot code off of lab results or interpret interpretations. You need a specific diagnosis/condition/notation of what those lab results mean.

I hope I've made sense, I've gone kind of cross-eyed with the amount of reports I've gone through so far today and have been unable to code.
 

Malevolus

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A better example came to mind.

Say you have an esophageal biopsy specimen and in the FInal Pathological Diagnosis it says 35 eosinophils present per hpf.

While technically this does meet the typical threshold for EoE, because documentation does not state EoE and it is a lab result, it isn't codeable. In this case, I'd first reference clinical history, and if there isn't any, I'd reference the visit/op/associated report for the service. In this case, assume no other information is available, and the provider cannot be queried, I personally would not be able to code this service without some kind of additional information.
 

danachock

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Hi Malevolus
I will try to help with what I can. There is quite a bit of information and questions. Please reach out if I may have missed something alright.
Okay, first you don't have access to the patient's chart. May I assume that a referring facility sent you the specimen for pathology review. This type of event does require a lab order that also requires a valid diagnosis code (the reason on why they are sending it to your facility for review). If your facility is receiving specimens with a lab order that simply states "rule out/rule in" or otherwise - you will want to talk to your supervisor and also bring in your medical director on this for attention. This could be an accessioning issue. They receive the specimen and without knowing better receive documentation that states something on why the specimen was received but not being a coder or know better they don't realize that they don't have a valid diagnosis code.

Next you stated "I recently started coding several lab tests - 88334, 88335, 84165, 84166" - I really think you meant to state 86334, 86335, 84165 & 84166.
Exactly how is the pathology interpretation stated? Is there anything stating its abnormal?

This also could be a teaching moment. Reach out to your pathologist(s) and ask them if such and such occurrence is an abnormality for a patient. If they reply and state - that Yes, it is. Proceed to ask them why it is and place that information in your notebook for future reference.

The only thing I found alarming from your random statements on your first post was about the spike. The other statements were simply findings - the pathologist's interpretation on what they saw for reimbursement.
Just to let you know - A characteristic monoclonal band (M-spike) is often found on serum protein electrophoresis (SPE) in the gamma globulin region and, more rarely, in the beta or alpha-2 regions. The finding of an M-spike, restricted migration, or hypogammaglobulinemic SPE pattern is suggestive of a possible monoclonal protein. Usually additional testing would be performed at this point to rule out or rule in a diagnosis.

Intestinal resection "adenocarcinoma present at 20cm from cecum" statement. I wouldn't even bat an eye stating ascending C18.2. The cecum per the SEER website (https://training.seer.cancer.gov/colorectal/anatomy/figure/figure1.html) is like the beginning. If there was no mention of a resection or anastomosis or prior surgical scar mentioned in the gross description; since this was a resection that is how I would state it. Just take I would also note that in my notebook coding this scenario.

Next your second post, "35 eosinophils present per hpf". That seems short like there was possibly more to state. I don't think I have ever had a pathology interpretation that short (lack of words). I usually see something like "see comment" when something so short like that is stated. Our pathologist isn't always in a position where they can state that EOE is what is happening due to other possible reasons. It also could be lack of information between the location of specimen or otherwise between the surgeon and the pathologist's. You know darn well our pathologist's are stating clinical review is necessary at this point because they are simply unsure.
It is alright - we all know they are going to protect themselves and just state what they know. However, there are several reliable resources online that state that high power field eosinophils isn't a "normal" finding in the esophagus. I will utilize the R85.7 diagnosis at this point. I have to use this for also rare stuff found regarding GVHD when they state rare or abnormal cells found.

Again, I apologize if I missed anything. Please let me know if I missed anything and have a wonderful evening!
Dana
 
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