Wiki Unbundling lymph nodes from a radical neck dissection

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Shekendan

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Hi all!
We would like to get an opinion on unbundling and reporting lymph nodes correctly that would stand up to an audit on a radical neck dissection. I'm warning you all ahead of time, this is kind of lengthy to read but i need to give all info ;)

Per Paget's - it states "report 88307 once per each node group that is individually identified and diagnosed; for example, if nodes from both sides of the neck come to the lab in separate containers, post 88307 x 2, alternatively report 88307 multiple times if the surgeon orients the overall dissection in such a way that the pathologist is able to report individually on the nodes at each level".

On the case that we were working on, we were able to separate out the nodes from each level (and it was documented in the report which specific levels positive lymph nodes were found in) and part of the report in question it was set up as:

Lymph node, right neck levels II–V, modified radical neck dissection:
- Metastatic squamous cell carcinoma in at least 8 of 28 lymph nodes (8/28).
- Largest metastatic focus is 2.5 cm (involves at least 6 matted lymph nodes); extranodal extension present.
- Metastatic carcinoma is present in levels II, III and IV.
- Metastatic carcinoma invades skeletal muscle.

With the lymph node codes as being 88307 x 3 and 88305 x 1 (as level 5 node only had 2 nodes in it and our pathologists don't like to upcode to the 307 unless there's 3 or more nodes)

Now our question is- Is this enough documentation to hold up to an audit or would we have to set it up such as:

- Level II: 3/8 positive nodes
- Level III: 4/4 positive nodes
- Level IV: 3/3 positive nodes
- Level V: 2/3 positive nodes
(and I know my math isn't correct on this from the documentation above, I was just giving an example)

And also, our gross description for this case separated the nodes by level and the doc did mention which levels the positive nodes were in - so would the first example be ok or would the 2nd one - or if even both would be alright?

Thank you in advance for the brave souls that wanted to tackle this lengthy post and give us your opinions!! :cool:
 
the surgical path codes are based on the submitted samples. Most of the time a radical neck dissection will submit everything in one container, this is counted as one specimen and you cannot separate it out. They then take this and make several separate slides and will label them A1, A2, A3... and so on, these are separate slides of the same specimen labeled A. This is just one specimen and you can have only one surgical path code. from the looks of what you reported, you have only one sample. It does not matter that the pathologist or the surgeon can identify the levels the nodes came from, it has to do with how many containers are submitted and what is in the container. a regional resection of lymph nodes submitted in one container would be the 88307 however if they are split up (and often are) then you use the 88305 for each of the different containers unless identified as a sentinel node. If the regional resection is all in one container the you report the 88307.
 
I respectfully disagree with Debra on this one. I think Padget (this resource: https://www.apfconnect.org/pathology-service-coding-handbook.php) is clear that even if the lymph nodes are received in one container, if they are identified as from different levels, they can be individually charged 88307.

In answering another question about containers/specimens, I found this useful resource that is free:http://grossing-technology.com/home...overcies-in-cpt-coding-in-surgical-pathology/

In Padget's resource, he has a very lengthy discussion about how the number of containers does not equal the number of specimens.

Also, in this case, level 5 could be coded as 88307. If your pathologists code 3 or more lymph nodes as 88307, there were a total of 3 nodes examined in this specimen, with 2 of the 3 nodes positive for malignancy, the 3rd node without malignancy.
 
perhaps it is a difference in how the providers document. Ours clearly identify the specimens as A , B , C ect. many times for the radical neck dissection it is al listed as specimen A. When documented this way it must be coded as one specimen and the coder cannot take separate parts and codes as different specimens.
 
I see your point, Debra.

Shekendan, it could be useful for you to post the report in it's entirety (minus identifying information) to best answer this.
 
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