Discussion on Coding & Documentation for Pathology Specimens

In determining the most appropriate procedure per specimen, per case sometimes knowing the organ or anatomic site is not enough.  Many organs are listed under multiple codes, with some on every level of service.
 
The unit of service for surgical codes 88300-88309 is the specimen. CPT defines as “tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis.”  The service provided for each specimen is “accession, examination and reporting.”
 
A “listed” specimen is one that’s specifically named in the 88302-88309 code series in CPT. There are 175 entries distributed among the five codes, and they account for approximately 230 different types of tissue or specimen scenarios. If the tissue you’re working on matches a listed specimen, report the code under which the entry appears. Listed specimens typically can’t be “up-coded” to account for extraordinary circumstances; for example, a non-incidental appendix is billed with CPT code 88304 even when it’s diagnosed with cancer.
 
Many codes are chosen not just by type but also by final diagnosis.  Several specimens are assigned to a given level depending if they are neoplastic or non-neoplastic, skin cyst vs skin lesion or lipoma vs soft tissue mass.  Procedures also play a part in selecting the appropriate codes for some specimens such as TUR bladder, cervical “cone,” or sterilization and keywords such as biopsy, resection, partial/wedge should be clearly documented in the report to ensure accurate coding and support the code in a charge audit.
 
So, you've coded the gross and microscopic codes for the specimen or specimens submitted. Sometimes for a case that is all that is required.  Others times not so. There are many additional services that can be performed to the primary exam, in some instances to assist in rendering a diagnosis.  Such as   decalcification, frozen sections, touch preps, staining for organisms or other cellular abnormalities, IHC stains, in situ hybridization, flow cytometry, etc.  There are only a few select codes that are considered add-on codes and all others are not considered add-on codes by AMA definition but you would rarely see one reported without a gross and microscopic code (88302-88309).
 
Proper and complete documentation in the medical report for any additional service is essential.  It is important for two reasons:  Again from an auditing standpoint and for a coder who is coding the case.  In reviewing or coding a report for  additional services, documentation should state: 1) was a separate service performed, 2) which specific service was performed, 3) what specimen(s) does the service(s) relate to and 4) how many times was the service performed with each specimen.  This information enables the auditor/coder to report the most accurate CPT code for the service and how many units to report. Additional tips which may be helpful are:

• Document the stain that was used and its results. This will help determine the purpose of the stain to choose the correct code. It can’t be assumed, for example, that iron stores mean the specimen was examined by an iron stain.
• If multiple specimens and/or blocks are stained, document which specimens and/or blocks the stains were performed on and the results.
• If a special stain didn’t yield a diagnosis, do not use words like “normal” or “noncontributory.” This tends to mean that the service was not medically necessary. Rather “GMS stain negative for H. pylori” or “Iron stores confirmed by Iron stain.”
• Be sure to specify the technique or approach used to obtain a diagnostic result. Is it an IHC stain, in situ hybridization study, etc. Was the approach qualitative, quantitative or semi-quantitative and if it was manual or computer-assisted.
• Don’t assume when a bone specimen is submitted, a decalcification is reported. Document decalcification in the report. Code 88311 is reported once per specimen.
• Clearly document for intraoperative consultations. If the finding was due to a gross only exam (88329) or if a microscopic diagnosis is given. If a microscopic diagnosis is given, is it based on a frozen section (88331), touch prep (88333) or both (88331/88334). If both clearly document the specific site each was taken.