Controvercies in Surgical Pathology cpt Coding

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The most cases of CPT coding in surgical pathology are simple. They do not require additional explanations or adjustments. However, there are coding situation when correct coding needs judgment and understanding CPT coding principles. Some CPT coding provisions have controversies which will be addressed in following sections.

The controversies in CPT coding in surgical pathology reflect both complexity of some surgical pathology procedures and specimens and ambiguity in CPT manual, as well as interpretations and recommendations of coding authorities. These circumstances make some coding artificially complicated requiring explanations and clarifications. However, it is necessary to reiterate that coding authorities’ recommendations have the upper hand and they must be honored.

 Container vs. specimen

 The specimen to be coded arrives in the surgical pathology laboratory in different ways but always in a receptacle that is called a container. The definition of the container is broader than a container/bottle itself. It can be a bag for a wrapped extremity or a Ziploc bag for kidney stone, or a safe tissue trap for products of conception.  In a case of the latter, different containers might be caused that material was too voluminous for one container or they were done the same day with some intervals. In essence, the first is one specimen for the pathologist’s attention, but the second is two or more for separate attention because it might have a medical meaning.

A “specimen” is not equal to a “container.” For some reasons, in one container can be more than one specimen separately identified by a suture/s, ink, clip/s. The requisition form can identify different specimens in the same container by size, shape, consistency, etc. For example, if two skin biopsies with one of them with a suture were received in one container, they are two separate specimens as far as coding concerned. However, these situations are exceptions from the common practice. They are mentioned to stress complexity of relationship between “specimen” and “container” definitions.

The CPT coding in surgical pathology goes parallel with computerized specimen accession. The container’s (now with a bar code) surgical number identification is the corner stone of
patient’s safety. Containers must be saved for a certain time with their identification numbers owning possibilities of numerous inquiries during grossing, processing and signing out. Billing considerations cannot interfere with the fundamental methodological principle as the specimen identification.

One container one specimen compromise as a preliminary CPT coding

One container one specimen principle can be a compromise with established realities of computer dominance in every day practice.  Compromise requires consensus in understanding and actions according this understanding otherwise the specimen – container compromise cannot be carried out. Both parties in the process clinicians (physicians, nurses, assistants) on one hand and pathology (pathologists, grossing personnel, accessioners) on the other hand use computer methodology, including Electronic Privacy Identification Center methodology (EPIC), to keep track on specimen, starting from labeling during the surgery to specimen identification in the laboratory to specimen charge coding to specimen charge control by the payer.

Following the one container one specimen principle, that is covering 95% of coding situation, would balance both extremes in coding approaches: aggressive voluntary unbundling and extraordinary cautious bundling. We cannot resort to some exquisite situations. If the principle container equals specimen were abused, this practice should be stopped, but otherwise this principle is only practically durable. Some cases of obligatory bundling can be solved through effective informative communication between accession and billing stuff. However, at the accession stage every container must have the surgical number identification with an automatically generated by the computer program CPT code. This provision prevents from unnecessary confusion in specimen’s identification that is a warranty of patient’s safety.

Some examples can illustrate one container one specimen principle as a compromise.

Let’s take a completely incomprehensible bizarre from medical stand point on the border with malpractice situation when esophagus, stomach, and duodenum biopsies were placed in one container. Even if the pathologist were able to distinguish them, sometimes it would be difficult and this difficulty has a diagnostic value. What about the technical component? The technical component is understandably only one 88305 code. Is the professional component 88305 x 3? One charge would not destroy financial standing of the pathology department, but separation them can cause confusions if the specimen’s identification numbers were changed to justify three charges.

Uterus and cervix. Uterus body and uterus cervix usually are one specimen in one container after hysterectomy. But they can be in two containers for many reasons. It would be unreasonable to combine them/bundle in one code/charge specimen because by essence they are two specimens which require separate attention because they can be a result of different operative actions. At least, at the accession stage they should have different identification and in the computer system they automatically get a separate CPT code.

Concrete items of compromise can be straightened out at the local level with third party payers (Medicare contractor, state Medicaid agency, or some major private insurers). A billing manager or a surrogate with an obligatory approval of the pathologist can make adjustments without interfering in the specimen identification after the sign out. There should be developed a special protocol for such adjustments in the institution. The initial coding process, however, should follow one container one specimen principle.

 Bundling/disbundling

 The bundling and disbundling question is the most controversial and it naturally depends on the approach to specimen and container issues. Actually, the premise of container specimen compromise serves the practical solution bundling/disbundling rules.

Mandatory bundling is required by unwritten rules established by coding authorities for some specimens when if they were submitted in separate containers.  Although it looks logic that mesenteric lymph nodes are part of the resected colon, but a legitimate question arises why they were send separately. The same applies to lymph nodes in mastectomy or larynx resection. The list can be expanded to adenoids and tonsils, adnexa and with uterus, hemorrhoids, nasal polyps, multiple fingers and toes. Anyway, the uncertainty about the reason of being placed will remain: is this a negligence accident or clinician meaning. It is wrong to sort it out at the accession level due to specimen identification consideration (see section one container one specimen compromise0 and unreasonable at the final charge code owning to rare occasions of this situations.

Disbundling, or unbundling, premise is controversial and more complex. It requires medical judgment and certainly cannot be applied at voluntary accession level, although can be practically solved by the automatic computer dictionary program.

The Whipple procedure is one of the most obvious examples of the controversy. The specimen after Whipple procedure as a rule arrives in one block (pancreas, duodenum, stomach, spleen), although there might be some variants. According to the College of American Pathologists (CAP), the Whipple procedure is only one specimen for coding, Level VI 88309 (CAP TODAY June, 2005). Some institutions code it as two (Level VI and Level V) specimens. Why not three specimens? Or, as it is recommended by Dennis Padget’s “Pathology Service Coding Handbook” (1), spleen, segments of duodenum and stomach, gallbladder, omentum, as well as lymph nodes can be coded additionally.

A different example is radical cystoprostatectomy in one operative block in one container. If the bladder were removed due to urothelial carcinoma and the prostate for adenocarcinoma each can be coded as 88309, and the computer dictionary should have 88309 x2.

In the case of pelvic exenteration when the rectum is resected due to adenocarcinoma as en block with uterus and bladder, the computer dictionary should include 88309 x1 and 88307 x 2 for bladder and uterus, however if carcinoma were found in the bladder or uterus or ovary they should have 88309. Anyway, the specimen can be accessioned as 88309, but the adjustments should be made after the pathologist’s report by the pathologist or billing manager.

Sometimes, a stillborn fetus is sent in one container with a placenta. As an obvious mishandling of the specimens, this exquisite situation should be managed differently from one specimen one container compromise principle. Those are definitely two specimens with completely different protocols where the fetus can be treated as an autopsy if certain conditions were met. The laboratory should request a resubmission them as two specimens in two containers with different requisition forms. They should be CPT coded and processed differently. In opposite to marked/ unmarked tonsils in one container, when the coding compromise would not be of significant importance, any confusion in specimen identification can have serious consequences.

Twin placentas are interesting example of ambiguity of disbundling provision. As usually placentas are marked by clamps, but the accession person cannot know it unless the specimen is examined. The computer dictionary should have a provision for multiple placentas. By the way, two codes for placentas (88307 – Placenta, Third Trimester and 88305 – Placenta, Other than Third Trimester) are confusing because these data are often omitted in the requisition forms and justification of this separation is questionable owing to technical difficulties and diagnostic problem while examining placentas at early stages of gestation.

These examples of rare coding situations of disbundling of complicated specimens only confirm that accession preliminary coding can be adjusted or by special computer dictionary provisions or after the pathologist’s report. The main thing is that coding consideration should not interfere with surgical number identification.

Lymph node, Regional resection

 The definition “Lymph node, Regional resection” is the main difficulty in lymph node CPT coding. Procedural versus arithmetical approach to the specimen assessment is the core of the problem (2).

Many practices have a simple rule that two or more lymph nodes from the same anatomic site constitute “regional resection” for CPT coding purpose. The rationale behind it is in uniformity and consistency from case to case, defensibility during an audit. However, this approach does not reflect the essence of the Current Procedural Terminology (CPT) that “is a systematic listing and coding of procedures and services”, as it is stated in the first line of the Introduction. The procedure is the main determination for the CPT code. Divergence from the procedure approach complicates charge coding in surgical pathology. Only one lymph node or even the absence of any cannot change the nature of the procedure. The AMA’s CPT coding manual emphasize that the code “reflects physician work involved.” “Conventional wisdom”, in Dennis Paget’s words, “suggests code 88305 be reported when the regional lymphadenectomy intended by the surgeon is found to be node-free.” However, in this situation conventional wisdom is in the contradiction with the principle of CPT coding in surgical pathology according to the AMA’s manual. It is easier for coders to have a rule: one lymph node – biopsy (88305), two or more in the same specimen – “regional resection” (88307). The amount of lymph nodes does not represent “regional resection” but the nature of surgical action does. If the lymph nodes are not intended to be taken out from a region as a treatment but for diagnostic purposes, they are biopsies. In the situation of a block/packet/fragment removing even one lymph node or none constitutes “regional resection.”  During the accession is not clear how many lymph nodes will be found in the submitted resected adipose tissue anyway.

The word intended has some weakness in interpretation, especially for coding practitioners facing an ignored or skeptical audition. In surgical practice the word intend means commonly accepted method of surgical procedure. For example, in prostate resection it means lymph nodes removal as part of pelvic lymph node dissection (PLND) as individual packets.

How many lymph nodes are removed and discovered depends just as much on the anatomy as it does on the surgeon’s skill, as well as on the pathology department’s procedural ability. The latter includes methodology of fixation, discovery during grossing, and histology processing.

However, approaches to this problem can be different at the local compliance level that should be followed for consistency the coding practice until the coding authorities issue a definite regulatory document.

Tissue/procedure vs. diagnosis

The CPT coding section for surgical pathology is design predominately by organ/tissue definition, but includes also diagnoses, for example, cholesteatoma, ganglion cyst, Lipoma, etc.).

Neither clinical diagnosis, for example tumor, nor additional efforts to its achievement do not have serious input in selection of the CPT code despite the popular believe, although the increase  from Level I to Level VI does reflect complexity of the specimen.

If the denotation is not mentioned any voluntary discretionally upcoding is not permitted.

Bone – bone resection, but femur Ewing’s sarcoma with enormous amount is no more than one code      unless there are local adjustments.

The last thing is to apply the fairness criteria in the correct choice of the CPT code in surgical pathology.

Lipoma is one of the examples. Lipoma is kind of soft tissue benign neoplasm. Lipoma can be an innocent lamp on the back, a large fatty tumor mass in the thigh or intradural tumor mass with clinical symptoms, etc.  The CPT manual specifically denotes “Soft tissue, Lipoma, 88304, Level III”. It is not a difficult specimen in surgical pathology. The problem is that sometimes the clinician suspects, or tries to exclude, a malignant neoplasm. The specimen is sent as “mass”, sometimes enormous size. The pathologists obliged by the rules examine each 1 cm section. If the pathologist’s diagnosis is “Lipoma” the code is Level III 88304, although the specimen was accessioned “Soft tissue tumor, extensive resection” according to the requisition form. However, if the pathologist reports myxoid liposarcoma, the preliminary coding would be correct although the amount of efforts involved in examining the specimen is the same except additional IHC which are coded and charged separately anyway.

In general, the diagnosis should not interfere with CPT code unless is specifically noted in the manual, like in Lipoma example. Of course, the neoplastic specimens are an exception.

The term “neoplasm”, according to Dorland’s dictionary, defines “any new and abnormal growth; specifically a new growth of tissue in which the growth is uncontrolled and progressive.” Without engaging in theoretical discussion because a kelloid in also abnormal growth, but not a neoplasm, practice distinguish in accordance with ICD-9- CM classification malignant, benign, or unspecified neoplasm.

The term “Neoplastic” in the CPT coding manual refers to malignant neoplasm or at least with potential malignant features as for example carcinoids. This the bottom line to distinguish specimens as Level VI 88309, Neoplastic.

Fibroma, neuroma, leyomyoma, insuloma are also neoplasms but in most instances benign. They are not Neoplastic as far as CPT coding is concerned.

Unless specifies in the surgical pathology code specimen listings, upcoding for malignant or other neoplastic diagnoses is not appropriate, but there is a quoted already sentence in the manual:  Any unlisted specimen should be assigned to the code which most closely reflects the physician work involved when compared to other specimens assigned to that code.

This is a gray area in the CPT manual.

Retroperitoneal mass is not listed in CPT manual but it is close to listed Mediastinum, mass Level V 88307 that makes reasonable this extrapolation.

For example, if a malignancy is fibromatous uterus Level V, 88307 is revealed by the pathologist, in this situation the code can be changed by the pathologist/billing manager for Level VI 88309 according to the pathologists’ report. If in the thyroid nodule a malignancy is discovered, the code should remain the same because there is no a code for neoplastic thyroid. It would be a creative coding that is not encouraged by coding authorities. Unfair, but this is the rule.

If in skin excision melanoma is diagnosed, the code remains Skin biopsy, Level IV 88305. Even in the case of wide excision due to melanoma, the code is Skin biopsy Level IV88305. Some computer dictionaries follow still available on line the University of Michigan Health System Specimen to Charge Code Rapid Finder List’s (3) recommendation to have two additional denotations: 88309 Skin – deep excision/re-excision with tumor; 88307 Skin – deep excision/re-excision w/o tumor. These denotations do not exist in CPT manual. They are an extrapolation from Soft Tissue Tumor, Extensive Resection, Level VI 88309 and Soft Tissue Mass (except Lipoma) – Biopsy/simple Excision Level V 88307. Unfortunately, this recommendation has a trap of a voluntary assessment of how deep is the skin deep excision. Obviously, it is difficult to do this assessment during the accession. The billing manager cannot be always familiar with the details of the procedure, but this can be sorted out only at the local level. However, unless a denotation is not authorized by AMA and CAP, this is no more than opinion, a voluntary coding decision. In general, most coding consultants recommend no higher CPT code level than 88305 for any specimen that accurately translated to a “skin” ICD-9-CM diagnosis code.

In dermatopathology, the diagnosis has more influence than in other areas of CPT coding in surgical pathology (4).

Disclaimer

 These materials do not represent official advice of the CAP, AMA, CMS or other governmental institution. The information will not bear any liability for its application and will not prevent any dispute with a third-party payer.

References

1. Padget Dennis. Pathology Service Coding Handbook; 2010 Version 10.2, Chapters 4, 5.

2. Dimenstein IB. Lymph Node Coding in Surgical Pathology. LabMedicine 2005 36: 602-603.

3. University of Michigan Health System. SPECIMEN TO CHARGE CODE RAPID FINDER LIST. http:// www. pathology.med.umch.edu/intra/templates/cribsheet.pdf. Accessed May 10, 2010.

4. Dimenstein IB. CPT Coding in Dermatopathology. LabMedicine 2009; 40: 151-156

 

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