Breast

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 Breast is well represented in the CPT coding manual. There are four main breast descriptors in the CPT coding manual’s surgical pathology section. They encompass almost all clinical situations.

Level IV 88305

Breast, Biopsy, (Case #3-1)

Includes needle breast biopsy (Case #3-1), incisional biopsy, fibroadenoma or other mass not requiring margins evaluation. “Not Requiring Microscopic Evaluation of Surgical Margins” are the key words that distinguish this code from two below. Specimens that represent only margins of the lesion are by essence an incisional biopsy as far coding is concerned (Case # 1 H-L). Breast biopsy without microscopically margins evaluation encompasses other clinical situation for example as breast cyst excision (Case # 2-A).

Breast, Reduction Mammoplasty is a separate entity (Case #2-B, C).

Level V 88307

Breast, Excision of Lesion, Requiring Microscopic Evaluation of Surgical Margins.

Breast, Mastectomy- Partial/Simple.  (Case #1)

Includes lumpectomy (e.g. tylectomy), wire localization excision, the entire radiologically identified mass with margins evaluation. The pathologic diagnosis must reflect microscopic margins evaluation.

Level VI 88309

Breast, Mastectomy-with Regional Lymph Nodes. (Cases #3 and #4)

Includes radical or modified radical mastectomy, simple mastectomy with regional lymph nodes. Lymph nodes even outside the axillary tail should be bundled as one specimen, except a sentinel lymph node which coded/charged separately.

The case of partial mastectomy with margins evaluation (Case #1) is taken as an example of practical CPT coding in surgical pathology. The goal is to guide through the sequence of stages while a CPT code is generated. This case scenario includes all basic principles of CPT coding in surgical pathology.

Case #1    CPT coding STAGES in surgical pathology laboratory

Actually, this is a real case that developed in a surgical pathology setting in an academic institution. As a realistic fiction, it reflects a typical coding situation. This case has a “plot” with some mistakes which are good to learn (better to learn from somebody’s mistakes).

A 65- year- old woman was diagnosed with left breast adenocarcinoma on a needle biopsy. Operation: left central breast lumpectomy with sentinel lymph node biopsy and left level 1and 2 left axillary dissection.

The pathology department received 12 specimens (3 frozen sections and then 9 specimens in separate containers). Each specimen was accompanied by a requisition form that included the specimen’s description.

There are 3 stages of the process (accession, pathology report, and final CPT code for billing) and 3 main participants (accession person, pathologists, billing manager).

Stage One: Accession

Accession person matched the specimen’s description in the requisition form with an appropriate denotation of the accession program’s computer dictionary.

 

S/# Description CPT code Assessment
A Left Sentinel lymph node   (Frozen section) 88331Level IV 88305 correctdowncode
B #2 Lymph node  (Frozen section) 88331Level IV 88305 correctcorrect
C #3 Lymph node (Frozen   section) 88331Level IV 88305 correctcorrect
D Left Axillary dissection ,   level1 Level V 88307 correct
E Left Axillary dissection,   level 2 Level V 88307 correct
F Left partial mastectomy   (short suture superior)(long   suture lateral) Level VI 88309 upcode
G Left axillary mole Level V 88307 upcode
H-L Inferior, medial,   posterior, lateral, superior margins Level IV 88305 correct

The accession person hasn’t noticed that specimen A was marked as sentinel lymph node that is Level V 88307. The computer dictionary should be set as Frozen section Sentinel lymph node (88307) in opposite to a regular frozen section that usually goes with 88305 as a regular biopsy. Specimen F, coded as Level VI, 88309 is an apparent mistake by the accession person because the requisition form stated as partial mastectomy that is Level V 88307. More than likely the word “mole” in the specimen G requisition form has been read as “node.” The question would be: Why it was not accessioned as Lymph node biopsy Level IV 88305?  It was accessioned as Lymph Nodes, Regional resection because the institution practices accession all lymph nodes, unless it is specifically mentioned lymph node biopsy, as Regional Lymph Nodes resection. Lymph nodes coding require separate discussion (see subsection Lymph Nodes).

The institution practiced instant billing for the Technical Component (TC). The charge was automatically arranged the next morning after accession. Technically, a grossing person or a histotechnologist can correct some mistakes after grossing when the histology information (the number of blocks, special stains, etc.) is logged into the computer, but the final say belongs to the pathologist during the sign out.

Usually histotechnologists cannot influence pathologist’s actions regarding coding while the specimen is signed out by the pathologist, but it depends on the mode how the things are arranged in the department. Some institutions have a specially trained technical assistant to help the pathologist to sort out coding issues and prevent mistakes.

Stage Two:  The pathologist’s report

 

S/# Pathologic diagnosis CRT code
A Lymph node, sentinel, left   axilla, one lymph node, metastatic carcinoma 88331Level IV 88305
B Lymph node, sentinel #2,   left axilla, one lymph node, negative for malignancy 88331Level IV 88305
C Lymph node, sentinel # 3, left axilla, one lymph node, negative for malignancy 88331Level IV88305
D Lymph nodes, left axilla   dissection level 1; nine small lymph nodes, negative for malignancy Level V88307
E Lymph nodes, left axilla   dissection level 2; seven lymph nodes negative for malignancy Level V88307
F Breast, left partial   mastectomy; infiltrating ductal adenocarcinoma, the resection margins, no   lymphovascular invasion seen; the rest of the breast show an intraductal   papilloma; Estrogen/progesterone receptors, HER-2/neu, KI-67 Level VI88309Immunohistochemistry88342 x 4
G Skin, left axilla biopsy;   fibroepitelial polyp (skin tag) 88307
H-L The revised margin of   resection is negative for malignancy Level IV88305

 

The pathologist’s repot confirms that the specimens D and E (axillary dissection, level 1 and 2) are accessioned correctly as Lymph Nodes, Regional Resection, Level V 88307.

The pathologist only added four immunochemistry codes (88342) for estrogen and progesterone receptor, HER-2/neu and KI-67 stains. The accession mistake on specimen G went unnoticed, as other incorrect coding as well. The wrong charge for the Technical Component was not corrected by the pathologist.

In some weeks (two to four) after the sign out, the billing manager went over the coding for Professional Component charge. Discrepancies in coding were revealed and credited (marked in bold in the table).

Stage Three: Final billing CPT code

S/# Description CPT code Assessment
A Left Sentinel lymph node   (Frozen section) 88331Level V 88307 correctcorrect
B #2 Lymph node  (Frozen section) 88331Level IV 88305 correctcorrect
C #3 Lymph node (Frozen   section) 88331Level IV 88305 correctcorrect
D Left Axillary dissection ,   level1 Level V 88307 correct
E Left Axillary dissection,   level 2 Level V 88307 correct
F Left partial mastectomy   (short suture superior)(long   suture lateral) Level V 88307Immunochemistry88342 x 4 correct
G Left axillary mole Level V 88307 upcode ! !
H-L Inferior, medial,   posterior, lateral, superior margins Level IV 88305 correct

Some pathologists bundle H-L (margins) with the main lesion (F) considering it as one coding entity, but this is wrong. If the margins are submitted in different containers, they are subject for separate pathologist’s attention and separate report that means a separate CPT code.

 

The wrong coding of the specimen G hasn’t been noticed. By the way, the code should be Level III 88304, as skin tag. Later the insurance company revealed the mistake.

This case is not difficult because it does not have disputable issue, if the participant were up to the task. In general, the breast coding rarely is the source of coding concerns.

This typical for surgical pathology practice case of mastectomy has been chosen intentionally for detailed description with all “vagaries” of every day coding in an ordinary anatomical pathology department. The main goal was to show how understanding of the process and correct actions by participants (accession person, pathologist, and billing manager) can contribute to prevention of coding errors.

In all following case scenarios Stage 2 and Stage 3 will be combined in most cases for the sake of spare the presentation space. The data in the table titled “Final code billing after the pathologist’s report” assumes that the code is or ought to be approved by the pathologist with cooperation of the billing manager.

Neither breast biopsy, nor mammoplasty can bring any difficulty in coding. They are come out automatically during accession and, as a rule remain unchanged in final code after the pathologist’s sign out.

Case # 2

35 year-old women had a bilateral breast reduction mammoplasty surgery. During the surgery a cystic formation in her left breast was excised due to painful lump which did not produce fluid during fine needle aspiration. The laboratory received three containers with the cyst specimen in a separate container.

Accession and final billing code after the pathologist’s sign out

 

S/ # Specimen’s description CPT code
A Left breast cyst- fibrocystic   formation 2,5 x 2.4 x1.4 cm, benign Level IV88305
B Left breast, reduction   mammoplasty, breast tissue, benign Level IV 88305
C Right breast, reduction   mammoplasty, breast tissue, benign Level IV 88305

Although margins of the cyst (specimen A) usually are inked and gross description might notice that margins are not involved in the process (capsula of the cyst), the coding should not be as for specimen with margins evaluation. The pathologist’s diagnosis does not reflect evaluation of margins that supports CPT code as Level IV 88305. There can be other benign formations, discrete lesions, for example fibroadenoma/s, which do not require evaluation of margins.

In mammoplasty cases, the key word in the pathologist’s report is reduction what for CPT coding reflect medical necessity of the procedure, in opposite to other mammaplasty surgery.

 

Cases #3 and #4 might need some clarification.

Case # 3 Axillary lymphatic mapping before the radical mastectomy

A 46-year-old woman had had anterior and posterior left breast core needle biopsies which revealed infiltration ductal carcinoma, Grade II that led to operation left axillary sentinel node, lymphatic mapping and a month later a radical mastectomy. The first surgery presents some interest as far as CPT coding is concerned.

Case #3-1- Beast needle biopsy

Accession and Final billing code after the pathologist’s sign out

 

 

 

s/# Specimen description CPT coding
A Left Breast, Anterior, core   biopsy-– Ductal carcinoma in situ, cribriform type, nuclear grade II with   necrosis and microcalcifications, ER Positive 90%, PR positive 100% Level IV 88305, 88342 x 2
B Left Breast, Posterior,   core biopsy –Infiltrating carcinoma , Grade II with necrosis and   microcalcifications ER Positive 90%, PR positive 100% Level IV 88305, 88342 x2

 

 

 

Case #3-2 Lymphatic mapping

Two weeks after the needle biopsy left axillary sentinel node, lymphatic mapping surgery was performed. Lymph nodes specimens were sent in five containers.

Accession

 

S/# Specimen description CPT coding
A Left axillary sentinel node   #1 Level V 88307
B Left axillary sentinel node   #2 Level V 88307
C Left axillary node #3 Level V 88307
D Left axillary node #4 Level V 88307
E Left axillary tract Level V 88307

The final billing code after the pathologist’s report

 

S/# Specimen description CPT coding
A Left axillary sentinel node   #1- Two out of two lymph nodes contain metastatic carcinoma Level V 88307
B Left axillary sentinel node   #2- One out of one lymph node contains metastatic carcinoma Level V 88307
C Left axillary node #3-   Three lymph nodes, negative for carcinoma, Keratin stain examined on all   three lymph nodes Level IV 88305 88342
D Left axillary node #4- One   out of one lymph nodes contains metastatic carcinoma Level IV 88305
E Left axillary tract-   Fibroadipose tissue, negative for carcinoma, no lymph nodes identified Level IV 88305

This case is remarkable for lymph nodes coding. Besides specimens A and B, which are indisputable 88307, as sentinel nodes, by essence the surgery performed on this patient was axillary lymphatic mapping is a diagnostic biopsy although it has elements of regional dissection with excision. Specimens C, D, and E do not constitute Lymph Nodes, Regional resections Level V 88307. The common coding practice to distinguish them by the count of lymph nodes is irrelevant. The case # 3- 2 will be discussed in detail in the Lymph Nodes Coding section.

Case #3-3 Modified radical mastectomy

The radical mastectomy surgery was done in a month after lymphatic mapping surgery. The laboratory received one container of left breast and axillary contents. The coding was easy and correct.

Accession and Final billing code after pathologist’s sign out

 

S/# Specimen description CPT coding
A Left axillary sentinel node   #1- Two out of two lymph nodes contain metastatic carcinoma Level V 88307
B Left axillary sentinel node   #2- One out of one lymph node contains metastatic carcinoma Level V 88307
C Left axillary node #3-   Three lymph nodes, negative for carcinoma, Keratin stain examined on all   three lymph nodes Level IV 88305 88342
D Left axillary node #4- One   out of one lymph nodes contains metastatic carcinoma Level IV 88305
E Left axillary tract-   Fibroadipose tissue, negative for carcinoma, no lymph nodes identified Level IV 88305
S/ # Specimen’s description CPT code
A Left breast and axillary   contents- Left breast modified radical mastectomy with placement of tissue   expander- Infiltrating ductal carcinoma. One of four axillary tail lymph   nodes positive for carcinoma.  IMPERX x   5              88309, 88342 x 5 Level VI

Case #4    Mastectomy bundling

This case illustrates some difficulties in coding situation when bundling is required. It often generates a coding question.

A 64-year-old woman underwent a right modified radical mastectomy (axillary contents level 1 and 2) with additional right axilla level 1 and 2 dissection. A part of the axillary tail (3.2 cm x 1.9 cm) was submitted in a separate container. The surgical pathology department received 3 containers.

Accession

 

 

S/# Specimen’s description CPT code
A Right breast & axillary   tail Level VI 88309
B Adipose tissue axillary   tail, lymph nodes level 1 & 2 Level V 88307
C Right axillary level 1   & 2 Level V 88307

The pathologic report

 

S/# Specimen’s description CPT code
A Foci of residual   infiltrating ductal carcinoma, metastatic carcinoma to 3/9 axillary lymph   nodes , Grade II/III Level VI 88309
B Three lymph nodes,   metastatic carcinoma Level V 88307
C Right axillary dissection: Two   lymph nodes, right axilla, negative for                                  malignancy                                       88307 Level V

Final billing code after the pathologist’s report

 

S/# Specimen’s description CPT code
A Right breast & axillary   contents level 1& 2 Level VI 88309
B Right axillary dissection   level 1 & 2 Level V 88307

The billing manger changed the amount of coding entities from 3 to 2 according to the rule of mandatory bundling of a fragment of the axillary tail even if it was sent in a separate container. This rule of the mandatory bundling should be honored but it has many objections from practical approach. By the way, specimen B could be disbundled if the pathologist’s report would have reflected the difference between dissections. However, in practice nobody does it.

It is necessary to differentiate lymph nodes (level 1 and 2) as part of the axillary tail from separate axillary dissection. The axillary dissection 1 or 2 is a special procedure of lymph nodes excision depending on the relation to the pectoralis minor muscle. In CPT coding terms, this is Lymph Node Regional Resection, as it was in the case #1 where the specimens were submitted in different containers.

In the case # 4, the accession person received three containers and during the accession the main goal was to label them correctly as part A, B, C with the same surgical number. Two different containers cannot have the same surgical number and the same part letter. At this point, it is unclear why they were sent in different containers, although it might have had clinical meaning. It is not only a waste of time to solve this question at the accession level, but can bring confusion in specimen identification.  The computer automatically generates a separate CPT code that in the case of instant billing for the Technical Component goes the next morning for charge. The billing manger is able easily to change for Professional Billing, but the credit of Technical Component is questionable. By the way, it is a deficiency of instant billing for Technical Component.

Lymph nodes coding has some traps of voluntary consideration. This is the reasonable to discuss lymph nodes coding issues immediately after Breast section and before other subspecialties.

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.

Dimenstein IB: CPT Coding for Mastectomy (A Case Study). LABMEDICINE, 2006, Vol. 37(11): 654-656.

 

 

 

 

 

 

 

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