One specimen, or two?

Sundancer

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I'd like some opinions on how to count the specimen(s) in this case, based on how they wrote up the accession.

We're having some arguments over this w the path dept on how to count them based on how they accessioned the specimens as a single specimen (submitted), yet the gross supports that the tubes were id'd separately and in separate cassettes. Most of the coders and audit managers think this is ONE unit, as the specimen is written up as a single specimen (not Spec A. tube L, Spec B. tube R) so it doesn't qualify as separately submitted, despite the gross noting separate identification.


SPECIMEN:
FALLOPIAN TUBES, BILATERAL, TUBAL LIGATION WITH ID, RIGHT TIED

GROSS DESCRIPTION:
The specimen is received in one part labeled XX-19-xxxx; Txxxx, Xxxx and medical record number xxxx.

Received in formalin labeled "bilateral fallopian tube segments" are two tan-pink, cylindrical, grossly unremarkable fallopian tube segments, each measuring
2.0 cm in length x 0.5 cm in diameter. The right segment shows a portion of fimbria and is indicated with a suture. The specimen is serially sectioned and entirely submitted in two cassettes as follows: cassette 1 - right segment; cassette 2 - left segment.
 
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bbooks

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As the right was identified with a suture, probably 88302 X 2. What is the final diagnosis?
 

Sundancer

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Dx Z30.2 sterilization

The argument lies in how the specimen line is written up (accessioned) as a single specimen line

Fallopian tubes, bilateral, tubal ligation w/ id, right tied

and not as

A. fallopian tube, tubal ligation, Left
B. fallopian tube, tubal ligation w/ id, Right tied

We get that it is separately id'd, but to qualify as separately submitted does the accession line need to be A. + B. or is a single line stating bilat w/ id acceptable?

CPT states it must be separately submitted AND separately ID'd.

So what defines separately submitted? If that is the way the surgeon entered it on the lab req form, and then the way the lab tech/PA entered it into the lab software - does that negate consideration for separately submitted?
 

mitchellde

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It was submitted as a single specimen even though it has more than one part it is still one specimen as submitted. Had it been submitted as 2 specimen=s then that would be different. As documented you have 1
 

bbooks

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It was submitted as a single specimen even though it has more than one part it is still one specimen as submitted. Had it been submitted as 2 specimen=s then that would be different. As documented you have 1
Based on "Pathology Service Coding Handbook" by American Pathology Foundation, I disagree. As the material is copyright, I cannot quote here, but you can find the information on pages 90-92 of the latest version. There is a lengthy discussion of "Individual and Separate Attention," and it is confirmed that submitting materials in a single container does not limit to coding for only one specimen, and it specifically indicates that attaching a suture to one piece of tissue is an adequate method for identifying as a separate specimen.

The determination for "individual and separate" is ultimately required by the pathologist, not the surgeon. Similarly, if a surgeon submits two separate specimens, it does not always mean they are separately chargeable. Oftentimes TAH/BSO specimens come in separate containers but they may need to be bundled into one charge.

The reason I asked about the final diagnosis is because if specimens are separately charged, they must each have been named and diagnosed in the final diagnosis.
 

mitchellde

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good to know.. We always went with how the specimen was submitted. And I agree if it is identified as two separate attestation like specimen A and Specimen B we would use 2 units. But the way this one was submitted and treated, I would have to say it can only be billed as 1 unit.
 

bbooks

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But the way this one was submitted and treated, I would have to say it can only be billed as 1 unit.
The pathologist is unable to control how the specimen was submitted, and must report it in "Specimen" as it was received.

I'm still curious as to the final diagnosis.
 

Sundancer

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Hey bbooks,

It didn't hit me until now what you were asking for when you said 'final diagnosis', lol...I was thinking dx, Z30.2. Here's top half w the finding...


SURGICAL PATHOLOGY REPORT

DIAGNOSIS:

RIGHT AND LEFT FALLOPIAN TUBES, BILATERAL SALPINGECTOMY:
1. Complete cross section of bilateral fallopian tubes (right side
tied)
2. Fimbriated end present on right side

<Electronically Signed>
xx xx

MICROSCOPIC DESCRIPTION:
The findings are summarized in the diagnosis.


But as you see, they still list it as a single item, bilateral. If they had listed it here as A. and B. I would have been inclined to say yes, two units.

I tend to agree with Debra - it's all in how they wrote it up as a single line, and that's how they got it from the surgeon on the req form. It's a bit of a gray area, what defines separate submitted, isn't it.

I wish we had access to the handbook - I've made comment to my manager to see if we can somehow get access or see if our path docs have access and somehow get a copy. I can find bits and pieces when someone posts articles than I can find through public searches. But otherwise we are relying on CPT Assistant and such.
 

bbooks

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But as you see, they still list it as a single item, bilateral. If they had listed it here as A. and B. I would have been inclined to say yes, two units.
What I have seen in this sort of case, and also other instances where separately charged specimens are sent in a single container, the final diagnosis will not create additional specimens from the original. That is, if only a "Specimen A" is received, but contains two separately charged pieces of tissue, the final diagnosis will not reflect "Specimen A and Specimen B." The final diagnosis will list all of the appropriate diagnoses under the same specimen count as submitted by the surgeon. Another example of this might be when an adrenal gland is submitted in the same container as a kidney. If the pathologist wants the adrenal gland separately charged from the kidney, he/she will include that diagnosis under same specimen - he/she will not create an additional specimen listing. This is also what I see when twin placenta are submitted in the same container with one twin is identified with a clamp on the cord. At least, that is what I have seen across my work with 3 separate pathology groups.

So, in your case, both of the tubes were diagnosed and were reported as distinctly right and left, so I would still code 88302 X 2. HOWEVER (Isn't coding full of "howevers? :rolleyes:)these certainly can be gray areas. It's important for the practice to have an agreed-upon general policy for these types of situations. There should be agreement among the pathologist and that information provided to the coder so that there is no ambiguity with coding - or having to guess or make assumptions.

Curious...what does your pathologist say?
 
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