Gastroenterology

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CPT is a registered trademark of the American Medical Association.”

 

The CPT coding of gastroenterology specimens is simpler than both urology and gynecology due to less variants. Actually, also lymph nodes and bundling are the main difficulties.

Level II 88302

Appendix, Incidental

 Level III 88304

Appendix, Other the Incidental                           Colon, Colostomy Stoma

Diverticulum – Esophagus/ Small Intestine                  Gallbladder

                         Hemorrhoids                             Mucocele, Salivary

Level IV 88305

Colon biopsy    Duodenum Biopsy     Esophagus Biopsy      Gingiva/Oral Mucosa Biopsy

  Omentum Biopsy                Stomach biopsy            Tongue Biopsy

Level V 88307

Colon, Segmental Resection, Other than for Tumor

Liver, Biopsy- Needle/Wedge     Pancreas Biopsy            Salivary gland

    Small Intestine, Resection, Other than for Tumor

   Stomach-Subtotal/total Resection, Other than for Tumor

Level VI 88309

Colon, Segmental Resection for Tumor                     Colon, Total Resection

  Esophagus, Partial/Total Resection

  

Pancreas, Total/Subtotal Resection (Case # 1) and (Case # 4)

Small Intestine, Resection for Tumor          Stomach-Subtotal/Total Resection for Tumor

 Suggestions codes unlisted AMA’s CPT manual

 

Descriptor/code Comment
Colon polyp/88305Colon “donut”/88304Colon “donut”/88305Diverticulum-esophagus/88305

Diverticulum-small bowel/88305

Endoscopic mucosal   resection (EMR)/88305

Enterocele/88302

Enterostoma/88304

Fistula/88304

Omentum resection for tumor/88307

Omentum resection-other   than for tumor/88304

Oral cyst/88305

Oral mucosa biopsy/88305

Oropharynx biopsy/88305

Peritoneum tissue/88305

Peritoneum resection for   tumor88309

Pancreas tail resection/88309

Polyp  colorectal/88305

Polyp stomach, small bowel/88305

Rectum, biopsy88305

Rectocele/88302

Recto peritoneal mass for   tumor/88309

Spleen in Whipple   procedure/88307

Spleen in trauma/88304

Sublingual, submandibular,   submaxillary gland biopsy/88305

Sublingual, submandibular,   submaxillary gland/88307

Surgical margin/88305

In colon stomaIn resection for tumor   separately submitted 

Gastric, esophageal

 

 

Colon, intestine

 

 

Soft tissue debridement

 

 

Endoscopic mucosal resection does not have a presentation in the AMA’s manual. On one hand it is a time consuming procedure with all signs of resection of a portion of stomach or esophagus with the methodology of examination of margins as in a standard resection. However, by essence it is a biopsy diagnostically. Until, the official recommendation is issued, the CPT code would be recommended as 88305, like a biopsy, although 88307 would be appropriate if the third party specifically agrees.

Let’s take the most and controversial Whipple’s procedure. There are different approaches to this really complicated and time consuming specimen.

Case #1    Whipple procedure disbundling

A 69-year-old man underwent a Whipple’s surgery due to the Ampulla Voter cancer.

Accession

 

S/# Specimen description CPT code
A Common duct lymph node Level V 88307
B Hepatic and ciliac lymph   node Level V 88307
C gallbladder Level III 88304
D Frozen section- pancreatic   duct 88331Level IV 88305
E Biliary stent Level I 88300
F Stomach/Pancreas/Bile   duct/Duodenum Level VI 88309Level V 88307
G Periportal lymph node Level V 88307
H Cut edge of   pancreas/Excision Level  VI 88309

The final billing code after the pathologist’s report

 

S/# Specimen description CPT code
A Common duct lymph node,   excision- one (2.0×1.8×0.5 cm) benign lymph node, negative for malignancy Level V 88307
B Hepatic and celiac lymph   node, excision-five benign lymph nodes, negative for malignancy Level V 88307
C Gallbladder-   cholecystectomy,- mild chronic cholecystitis (no stones identified) Level III 88304
D Frozen section- pancreatic   duct- intraductal papillary mucinous neoplasm 88331Level IV 88305
E Biliary stent- blue   tube-like 8.5 cm in length, 0.3 cm in diameter Level I 88300
F Stomach/Pancreas/Bile   duct/Duodenum- infiltrating, moderately differentiated adenocarcinoma (1cm)   arises in the ampulla of Vater. The tumor extends through the duodenal wall   and invades into the submucosa without invading the muscularis propria. One   (retroperitoneal) out of eight lymph nodes is positive for metastatic   adenocarcinoma. Pancreas margin and common bile duct resection margin are   negative for tumor. Stomach and duodenal mucosa unremarkable. IMPERX, STAIN2 Level VI 8830988342×188313 x1
G Periportal lymph node, biopsy-   one (1.0×1.0x0.5 cm) lymph node, negative for malignancy Level IV 88305
H Cut edge of   pancreas/Excision- portion of uniloculer cyst (4.0cm) wall most consistent   with a macrocystic serous cystadenoma- adjacent pancreatic parenchyma with   focal mild chronic inflammation and fibrosis. Positive Keratin, Positive PAS,   Negative PASD stains. Level  V 8830788342 x188313×3

 

Specimen G was sent as a biopsy, and the billing manager changed correctly for Level IV 88305 Lymph Node, Biopsy. In specimens A and B the key word is excision that constitutes Lymph node, Regional resection Level V 88307.

The Whiplle procedure is designated by coding authorities as Level VI 88309 only. Some computer dictionaries designate to codes Level VI 88309 and Level V 88307. There are suggestions (Dennis Padget, Pathology Coding Handbook) to unbundle organs as pancreas, stomach, duodenum, even common bile, but the billing manager was right by changing for one code as Level VI 88309 because voluntary coding decision that defy official instructions are wrong. Specimen H is closer to Level V 88307 Pancreas, Biopsy by the diagnostic intention, although Level VI Pancreas, Total /Subtotal Resection are defensible.

Case # 2     Esophagogastroectomy

A 70-year-old man with cardiac achalasia and ephphrenic diverticulum underwent transthoracic esophagectomy with placement of jejunostomy tube. There were two specimens sent to pathology.

Accession

 

S/# Specimen description  CPT code
A Periesophgeal node Level V 88307
B Esophagus &stomach Level VI 88309

The final billing code after the pathologist’s report

 

S/# Specimen description  CPT code
A Periesophageal node,   biopsy-one (2.2×0.7×0.5 cm) lymph node, negative for malignancy, hyalinized   granuloma with anthracotic changes Level IV 88305
B Esophagus &stomach;   esophogogastrectomy-esophagus with a large diverticulum (4.0×5.9×3.3), no   evidence of malignancy, stomach with chronic inflammation, 12 periesophageal   lymph nodes, negative for malignancy Level VI 88309

The requisition form did not specify the specimen A which was accessioned as regional resection; the pathologist’s report defined the specimen as a biopsy, which it was indeed. The billing manager changed the code for Level IV 88305.  The clinical diagnosis has not mentioned tumor in specimen B. In opposite to stomach, every esophagus resection is Level VI 88309 Esophagus, Partial/Total Resection.

Case #3 Liver transplant

 

A 68-year-old man underwent orthotopic liver transplant due to cirrhosis with liver failure. During pathology examination three cancer foci were revealed.

Accession

 

S/# Specimen description CPT code
A Liver Level VI 88309
B Gallbladder Level III 88303
C Porta-hepatic lymph node Level V 88307

The final billing code after the pathologist’s report

 

S/# Specimen description CPT code
A Liver; orthotopic liver   transplant; three separate hepatocellular carcinomas; cirrhosis, stage IV ,   moderate chronic hepatitis C Level VI 88309
B Gallbladder- chronic   cholecystitis and focal chelesterolosis; one benign reactive lymph node Level III 88303
C Porta-hepatic lymph node,   biopsy- one lymph node, negative for carcinoma Level IV 88305

The CPT manual does not have a descriptor for liver transplant, and computer dictionaries use Level VI 88309 like as Lung, Total/Lobe/Segment Resection. The gallbladder’s lymph node is definitely part of the main specimen B. The lymph node is a biopsy by the clinical procedure because it was not intended as an excision owning the fact that the cancer was unknown by clinicians. The billing manager changed the code in specimen C for Level IV 88305.

Case # 4 Gunshot wounds to the abdomen (legal case)

A 16-year- old male underwent exploratory laparotomy due to gunshot wounds to the abdomen. There was a bullet extracted, as well as resected, the pancreas tail, the spleen, and fragments of anterior stomach wall and descending colon. All specimens were sent to the pathology in separate containers.

Accession

 

S/# Specimen description CPT code
A Metal foreign body Level I 88302
B Pancreas tail Level VI 88309Level V 88307
C Anterior stomach wall Level V 88307
D Descending colon Level V 88307
E Spleen Level IV 88305

The final billing code after the pathologist report

 

S/# Specimen description CPT code
A Bullet Level I 88302
B Fragment of pancreas with hemorrhages Level VI 88309
C Fragment of stomach   wall  with lacerations Level V 88307
D Segment of colon with round   lacerations Level V 88307
E Spleen with areas of   hemorrhages and lacerations Level IV 88305

CPT coding in this case is simple if follow the computer dictionary formal descriptors. However, it is obviously upcoded situation. The specimen B was accessioned as a Whipple procedure, because the computer dictionary does not have a separate Pancreas, total/ Subtotal resection denotation. Spleen does not exist in the CPT manual.

The gastroenterology biopsies do not have any CPT coding difficulties. The Medically Unlikely Edits (MUE) concerns, for example in 16 colon biopsies, are acceptable if the clinical diagnosis supports them a medical necessity. Many institutions included Giemsa as 88314 automatically with stomach biopsies.

The table # 1 is presented as clinical illustration of practical application of principles CPT coding in surgical pathology. Although most of the suggested codes are commonly aome can have a different approach.

Table 1.  CPT coding of the most frequent colon specimens.

 

Case scenario Identification specimen/blocks Pathology data CPT code Comments
1, Colon biopsies (terminal   ileum, ascending, transverse, descending colon) A1, B1, C1, D1, Normal small intestine and colon   mucosa 88305 x 4 Standard code
2, Colon biopsies (terminal   ileum + ascending, transverse, descending colon) A1, B1, C1, D1, Normal small intestine and   colon mucosa 88305 x 4 Specimen A contains   distinguishable diagnostic entities coded as one specimen
3. Sigmoid colon polyp A8 Fragmented villous adenoma 88305x 1 Biopsy code despite   multiple blocks and the neoplastic diagnosis
4. Colon polyps A1 Colon content, no mucosa   identified 88305x 1 Coded as biopsy despite   negative findings
5. Colon biopsies A1 – P1 Ulcerative colitis 88305 x 16 Multiple biopsies as   medical necessity
6. Colon stoma A1-A2 Colostomy stoma 88304x 1 Standard code stoma
7. Colon resection A1-A12 Crohn’s disease, appendix 88307x 1 Segmental resection.   Appendix is part of the specimen
8. Colon resection A1-A10 Intensive total   diverticulosis with perforation, peritonitis, total resection 88309x 1 Standard code for total   resection
9. Colon resection A1- A14B1-B 6C1-C 3 AdenocarcinomaAdenocarcinoma“Donut” free of tumor 88309 x 288305 Each segment is a separate   coding entity, the “donut” is submitted separately
10. Colon resection A1- A6B1-B4 Ulcerative colitis 88307 x 2 Total resection by two   segments
11. Colon resection A1- A4B1- B3 Gunshot wounds 88307 x 2 Two separate segments

The table is, in general, self explanatory, but some additional comments can be made due to limited space in the columns.

In case # 2, terminal ileum and ascending colon biopsies were placed for some reasons, probably by mistake, in one container. Although they are definitely distinguishable by morphology, they naturally could not be assigned a different code during accession, but there is no any reason to change the codes after the pathologists report as an extraordinary situation. Although if the pathologist or billing officer wanted they could justify it.

In case # 4, the clinician confused polyps with colon content due to inadequate preparation of colon, but the pathology work, especially technical part, is the same or more difficult. The code is justified as a biopsy.

In case # 5 multiple biopsies are justified for choice of treatment according to medical literature. The Multiple Unreasonable Edit (MUE) rules confirm this coding.

In case # 9, the “donut” is a surgical margin that is, by essence, a biopsy. It proximal and distal parts are not distinguishable; there is only one code because only one “donut” specimen was sent. The second “donut” has not been sent for some reasons. Although there are two segments of the same colon, both segments are coded separately without bundling.

When the “donut/s” specimen is submitted in the same container with resected colon this is one specimen even if the pathologist reports on each “donut” specimen the separate diagnoses. If colon and “donut/s” are submitted in separate containers, the question becomes complicated. If the surgeon sends the “donut” specimen in a separate container, it is unclear what prevented from placing in the same container. If the donut is mentioned on the requisition form of a separate container, it means that the surgeon draws attention to this specimen. In the example #9, there is only one donut specimen in a separate container, although usually are two donuts. It cannot be coded as 88309, but as a separate specimen it is 88305. The “donut” in the separate container is accessioned as a separate part of the surgical number with automatically generated CPT code by the computer.

This coding situation reflects practicality of the one container one specimen compromise principle under conditions of computerized coding during specimen’s accession.

In case # 10, together, two segments of non-neoplastic colon provide total colon resection, but it would be artificial to have two total resection of one colon.

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.

Below are the Letter to the LabMedicine from a reader (Pamela Youns) and the author’s (Izak Dimenstein) response, as well as Dennis Padget’s response in the e-mail to the author.

Thank you for sending the Q&A about “donuts”. I certainly agree with your response: the College’s advice is too broad. Clearly there are situations when the surgeon obviously intends and wants a distinct diagnosis for the donut(s) that comes with a colon resection. In those instances, one should separately charge the donut(s), just as one would any other separate specimen. The College’s answer is too arbitrary and confining, and I encourage a more reasoned approach to handling donuts in Pathology Service Coding Handbook.

As you might well have guessed, I respectfully disagree with the sentiment you express in the last paragraph of your response. But we’ve gone through the pros and cons of “one container/one charge” many times, and I strongly suspect we’ll both go to our graves not having convinced the other of the position we each hold so passionately on this topic.

Warm regards,

Dennis

 

 

 

 

 

 

      

    

 

 

 

 

 

 

 

 

   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C
D
E
F x1
G Periportal lymph node, biopsy-   one (1.0×1.0x0.5 cm) lymph node, negative for malignancy Level IV 88305
H Cut edge of   pancreas/Excision- portion of uniloculer cyst (4.0cm) wall most consistent   with a macrocystic serous cystadenoma- adjacent pancreatic parenchyma with   focal mild chronic inflammation and fibrosis. Positive Keratin, Positive PAS,   Negative PASD stains. Level  V 8830788342 x188313×3

Specimen G was sent as a biopsy, and the billing manager changed correctly for Level IV 88305 Lymph Node, Biopsy. In specimens A and B the key word is excision that constitutes Lymph node, Regional resection Level V 88307.

The Whiplle procedure is designated by coding authorities as Level VI 88309 only. Some computer dictionaries designate to codes Level VI 88309 and Level V 88307. There are suggestions (Dennis Padget, Pathology Coding Handbook) to unbundle organs as pancreas, stomach, duodenum, even common bile, but the billing manager was right by changing for one code as Level VI 88309 because voluntary coding decision that defy official instructions are wrong. Specimen H is closer to Level V 88307 Pancreas, Biopsy by the diagnostic intention, although Level VI Pancreas, Total /Subtotal Resection are defensible.

Case # 2     Esophagogastroectomy

A 70-year-old man with cardiac achalasia and ephphrenic diverticulum underwent transthoracic esophagectomy with placement of jejunostomy tube. There were two specimens sent to pathology.

Accession

 

S/# Specimen description  CPT code
A Periesophgeal node Level V 88307
B Esophagus &stomach Level VI 88309

The final billing code after the pathologist’s report

 

S/# Specimen description  CPT code
A Periesophageal node,   biopsy-one (2.2×0.7×0.5 cm) lymph node, negative for malignancy, hyalinized   granuloma with anthracotic changes Level IV 88305
B Esophagus &stomach;   esophogogastrectomy-esophagus with a large diverticulum (4.0×5.9×3.3), no   evidence of malignancy, stomach with chronic inflammation, 12 periesophageal   lymph nodes, negative for malignancy Level VI 88309

The requisition form did not specify the specimen A which was accessioned as regional

Case #3 Liver transplant

A 68-year-old man underwent orthotopic liver transplant due to cirrhosis with liver failure. During pathology examination three cancer foci were revealed.

Accession

S/# Specimen description CPT code
A Liver Level VI 88309
B Gallbladder Level III 88303
C Porta-hepatic lymph node Level V 88307

The final billing code after the pathologist’s report

 

S/# Specimen description CPT code
A Liver; orthotopic liver   transplant; three separate hepatocellular carcinomas; cirrhosis, stage IV ,   moderate chronic hepatitis C Level VI 88309
B Gallbladder- chronic   cholecystitis and focal chelesterolosis; one benign reactive lymph node Level III 88303
C Porta-hepatic lymph node,   biopsy- one lymph node, negative for carcinoma Level IV 88305

The CPT manual does not have a descriptor for liver transplant, and computer dictionaries use Level VI 88309 like as Lung, Total/Lobe/Segment Resection. The gallbladder’s lymph node is definitely part of the main specimen B. The lymph node is a biopsy by the clinical procedure because it was not intended as an excision owning the fact that the cancer was unknown by clinicians. The billing manager changed the code in specimen C for Level IV 88305.

Case # 4 Gunshot wounds to the abdomen (legal case)

Accession

 

S/# Specimen description CPT code
A Metal foreign body Level I 88302
B Pancreas tail Level VI 88309Level V 88307
C Anterior stomach wall Level V 88307
D Descending colon Level V 88307
E Spleen Level IV 88305

The final billing code after the pathologist report

 

S/# Specimen description CPT code
A Bullet Level I 88302
B Fragment of pancreas with hemorrhages Level VI 88309
C Fragment of stomach   wall  with lacerations Level V 88307
D Segment of colon with round   lacerations Level V 88307
E Spleen with areas of   hemorrhages and lacerations Level IV 88305

CPT coding in this case is simple if follow the computer dictionary formal descriptors. However, it is obviously upcoded situation. The specimen B was accessioned as a Whipple procedure, because the computer dictionary does not have a separate Pancreas, total/ Subtotal resection denotation. Spleen does not exist in the CPT manual.

The gastroenterology biopsies do not have any CPT coding difficulties. The Medically Unlikely Edits (MUE) concerns, for example in 16 colon biopsies, are acceptable if the clinical diagnosis supports them a medical necessity. Many institutions included Giemsa as 88314 automatically with stomach biopsies.

The table # 1 is presented as clinical illustration of practical application of principles CPT coding in surgical pathology. Although most of the suggested codes are commonly accepted, some can have a different approach.

Table 1.  CPT coding of the most frequent colon specimens.

 

Case scenario Identificationspecimen/blocks Pathology data CPT code Comments
1, Colon biopsies (terminal   ileum, ascending, transverse, descending colon) A1, B1, C1, D1, Normal small intestine and   colon mucosa 88305 x 4 Standard code
2, Colon biopsies (terminal   ileum + ascending, transverse, descending colon) A1, B1, C1, D1, Normal small intestine and   colon mucosa 88305 x 4 Specimen A contains   distinguishable diagnostic entities coded as one specimen
3. Sigmoid colon polyp A8 Fragmented villous adenoma 88305x 1 Biopsy code despite   multiple blocks and the neoplastic diagnosis
4. Colon polyps A1 Colon content, no mucosa   identified 88305x 1 Coded as biopsy despite   negative findings
5. Colon biopsies A1 – P1 Ulcerative colitis 88305 x 16 Multiple biopsies as   medical necessity
6. Colon stoma A1-A2 Colostomy stoma 88304x 1 Standard code stoma
7. Colon resection A1-A12 Crohn’s disease, appendix 88307x 1 Segmental resection.   Appendix is part of the specimen
8. Colon resection A1-A10 Intensive total   diverticulosis with perforation, peritonitis, total resection 88309x 1 Standard code for total   resection
9. Colon resection A1- A14B1-B 6C1-C 3 AdenocarcinomaAdenocarcinoma“Donut” free of tumor 88309 x 288305 Each segment is a separate   coding entity, the “donut” is submitted separately
10. Colon resection A1- A6B1-B4 Ulcerative colitis 88307 x 2 Total resection by two   segments
11. Colon resection A1- A4B1- B3 Gunshot wounds 88307 x 2 Two separate segments

The table is, in general, self explanatory, but some additional comments can be made due to limited space in the columns.

In case # 2, terminal ileum and ascending colon biopsies were placed for some reasons, probably by mistake, in one container. Although they are definitely distinguishable by morphology, they naturally could not be assigned a different code during accession, but there is no any reason to change the codes after the pathologists report as an extraordinary situation. Although if the pathologist or billing officer wanted they could justify it.

In case # 4, the clinician confused polyps with colon content due to inadequate preparation of colon, but the pathology work, especially technical part, is the same or more difficult. The code is justified as a biopsy.

In case # 5 multiple biopsies are justified for choice of treatment according to medical literature. The Multiple Unreasonable Edit (MUE) rules confirm this coding.

In case # 9, the “donut” is a surgical margin that is, by essence, a biopsy. It proximal and distal parts are not distinguishable; there is only one code because only one “donut” specimen was sent. The second “donut” has not been sent for some reasons. Although there are two segments of the same colon, both segments are coded separately without bundling.

When the “donut/s” specimen is submitted in the same container with resected colon this is one specimen even if the pathologist reports on each “donut” specimen the separate diagnoses. If colon and “donut/s” are submitted in separate containers, the question becomes complicated. If the surgeon sends the “donut” specimen in a separate container, it is unclear what prevented from placing in the same container. If the donut is mentioned on the requisition form of a separate container, it means that the surgeon draws attention to this specimen. In the example #9, there is only one donut specimen in a separate container, although usually are two donuts. It cannot be coded as 88309, but as a separate specimen it is 88305. The “donut” in the separate container is accessioned as a separate part of the surgical number with automatically generated CPT code by the computer.

This coding situation reflects practicality of the one container one specimen compromise principle under conditions of computerized coding during specimen’s accession.

In case # 10, together, two segments of non-neoplastic colon provide total colon resection, but it would be artificial to have two total resection of one colon.

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.

Below are the Letter to the LabMedicine from a reader (Pamela Youns) and the author’s (Izak Dimenstein) response, as well as Dennis Padget’s response in the e-mail to the author.

Thank you for sending the Q&A about “donuts”. I certainly agree with your response: the College’s advice is too broad. Clearly there are situations when the surgeon obviously intends and wants a distinct diagnosis for the donut(s) that comes with a colon resection. In those instances, one should separately charge the donut(s), just as one would any other separate specimen. The College’s answer is too arbitrary and confining, and I encourage a more reasoned approach to handling donuts in Pathology Service Coding Handbook.

As you might well have guessed, I respectfully disagree with the sentiment you express in the last paragraph of your response. But we’ve gone through the pros and cons of “one container/one charge” many times, and I strongly suspect we’ll both go to our graves not having convinced the other of the position we each hold so passionately on this topic.

Warm regards,

Dennis

 

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