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  Cracking the code: advice
  for CPT dilemmas

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Reprinted from July 1999 CAP TODAY

Carl Graziano

The increased threat to physicians and laboratories in recent years of federal fraud charges related to improper CPT coding has raised the importance of understanding correct code use and avoiding questionable practices, such as “upcoding” and “unbundling.”

But that might be easier said than done, the chair of the College's Professional and Economic Affairs Committee says.

"CPT coding is a somewhat arcane science,” says Stephen N. Bauer, MD, who also represents the College on the American Medical Association's CPT Advisory Committee. “Placement of a semicolon in the code wording, use of the singular or plural and the presence of words such as 'or,' 'and,' and 'e.g.' can really influence a code's use. The exact code wording should be noted when deciding whether a code is appropriate for a particular service and what services are bundled into that code.”

Hospital or laboratory pricing lists–charge masters–that abbreviate code nomenclature for simplicity can be one source of problems, Dr. Bauer notes. Such lists can mislead those who need to assign a code to a particular service, he says.

Another area of concern is proper coding for a specimen that required more blocks and slides than usual or proved particularly difficult to diagnose. Although the work involved exceeded that typically required of such a specimen, the assigned code still applies, Dr. Bauer says. Only in cases where the coding nomenclature allows for upcoding or unbundling is it appropriate to do so for billing purposes, he says.

Inappropriate focus on the number of containers in which specimens arrive can also cause miscoding, Dr. Bauer notes. “It does not matter if two specimens are submitted in a single container if they are separately identifiable for diagnosis. Two skin biopsies with one identified by a suture/ink or two skin biopsies identifiable by size are in both instances two separately codable specimens even if they arrive in the same container,” he says.

One test of whether the specimens are truly separate is whether the pathologist must handle and diagnose each lesion separately or can combine unmarked sections of the two lesions in a single slide. Multiple skin tags submitted in a single container without any identification can be combined in a single slide for examination and should be described with a single code. Two grossly distinguishable skin lesions of distinctly different size or character normally would be individually identified and separately submitted for separate diagnosis, and should be described separately.

Conversely, when a specimen is designated as a single unit in CPT, it is coded as such even if submitted in separate containers. If a breast and axillary lymph node dissection is separated and placed in two containers, it is still a modified radical mastectomy (88309). Seminal vesicles are part of a radical resection of the prostate and would not be separately coded, even if submitted in a separate container.

"It is important to be wary of coding advice that seeks to 'maximize reimbursement' at the expense of adherence to the coding language or to standards accepted by coding authorities,” Dr. Bauer says. Before 1992, the CPT codes for surgical pathology allowed pathologists a great deal of latitude, similar to that under the old standard of coding for office visits-the physician could choose a level of coding based on the amount of effort expended. But coding systems for surgical pathology and evaluation and management services put in place in 1992 replaced much of that discretion with greater standardization.

The use of “creative coding” suggested by consultants has attracted government attention in recent years and poses another potential hazard for laboratories, Dr. Bauer warns. Consultants' advice should be reviewed carefully for accuracy, he says. Similarly, a physician who believes a particularly difficult or unusual case merits higher payment and, to that end, upcodes or unbundles a claim, should do so with the knowledge that the claim might not pass muster with an auditor armed with a coding book, Dr. Bauer says.

The proper way to report unusually difficult or time-consuming cases is with use of modifier -22, Unusual Procedural Services, although Medicare will usually not increase payment when the modifier is used and some private insurers might not recognize the code at all.

The Professional and Economic Affairs Committee (PEAC), which the College has designated to develop and interpret pathology and laboratory medicine CPT codes, considers coding matters at each of its meetings. Often the PEAC works with other College committees and other pathology and laboratory organizations to develop proposals for keeping CPT current with pathology practice. The PEAC also is responsible for aiding pathologists' understanding of the payment policy and practice requirements that surround CPT code use. While only Medicare is contractually obligated to use CPT in its claims processing, nearly all insurers use the coding system in some way. As a result, the demand for correct coding information is growing. Many of the common questions relate to situations not specifically described in CPT or to the directions for use of multiple codes or units of service.

With its constant attention to coding matters, the PEAC has a firm grasp of coding issues as they arise and of the need for clarifying code use in response to confusion sometimes created by changing technology and practice patterns and others' misinterpretation of code use. The PEAC advises that the pathologist knowledgeable about the handling of a particular case personally assign the appropriate code or codes based on the services known to have been provided.

The following coding advice reflects particular areas of concern or confusion the PEAC has identified, and provides more specific discussion of many of the basic principles described above. Beginning next month, CAP TODAY will feature CPT coding advice in a question-and-answer format. The bimonthly column will answer frequently asked CPT coding questions identified by the PEAC or College professional affairs staff.

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Complex surgical pathology specimens with multiple organs and radical surgical procedures

In CPT, the specimen is the unit of coding for primary surgical pathology services 88300 to 88309. The specimen is defined as “tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis.” The intent of this direction is to treat tissues normally removed together as a single unit of service.

One should not code separately for the short segment of terminal ileum or the appendix that is part of a right colectomy for a colon carcinoma. However, it would be appropriate to code for a separate specimen when a segment of small bowel is submitted for evaluation of a lesion, such as ischemic bowel disease (88307) and the surgeon finds and submits a separate segment of sigmoid colon with diverticulitis (88307) or carcinoma (88309). Separate codes also are appropriate when other organs that are not ordinarily part of a specimen described in CPT are submitted and evaluated. A kidney, for example, is coded 88307; when the adrenal gland, an unlisted specimen, is submitted with the kidney, it must also be examined and should be assigned a code appropriate for the work involved, rather than 88307, adrenal resection.

When multiple organs are attached to one another or submitted in the same container, they should each be coded appropriately. Radical cystoprostatectomy is an example. The prostate and bladder may be, but are not ordinarily, removed together. These organs may be removed because of independent disease processes or because disease extended from one organ to another. If the bladder is removed for urothelial carcinoma and the prostate for prostatic adenocarcinoma, each examination is coded 88309. If the prostate is removed because urothelial dysplasia extended into the urethra and examination of the prostate was more limited than for a radical prostate resection, it would be more appropriate to use 88307 to describe the prostate. Pelvic resections or exenteration may be even more complicated to evaluate and code. A resection for advanced rectal carcinoma, for example, could involve removing the bladder and internal genital organs. These could be submitted as an en bloc resection or in separate containers. The rectum would be coded as 88309 and each of the other organs that constitute a separate specimen defined in CPT would usually be coded as 88307. If there were a distinct synchronous neoplasm, such as carcinoma of the cervix, this would warrant use of 88309 for the uterus, tubes, and ovaries included in the resection.

Similar consideration would apply to resection of the pancreas (88309). If the spleen were removed it would be coded as 88305, regardless of whether it is attached to the pancreatectomy specimen or submitted separately. A segment of intestine attached to the pancreas would also be coded separately as 88307.

Tissues that do not require separate evaluation would not usually be coded. For example, a neck dissection could include regional lymph nodes, vascular structures, muscle, and salivary gland. The regional neck nodes would be coded as 88307. The salivary gland would be coded as 88307. The muscle and vascular structure would not ordinarily be coded separately unless justified by a circumstance such as soft tissue extension requiring evaluation of margins.

Lymph nodes accompanying other specimens

Coding for lymph node examinations is a common problem. When the CPT designation specifically includes the lymph nodes (e.g. 88309, mastectomy or laryngectomy with regional lymph nodes) or when the lymph nodes are ordinarily attached to the specimen (e.g. a lymph node adjacent to the neck of the gall bladder with a cholecystectomy [88304] or colectomy for neoplasm with mesenteric lymph nodes [88309]), examination of the lymph nodes is not to be coded separately. A periaortic lymph node is not ordinarily removed with the colon or gall bladder and, if submitted, would be coded separately. When multiple regional lymph node resections are dissected, each is examined separately to establish the presence and extent of metastases and each dissection is reported separately. A radical prostate resection does not include regional lymph nodes and each regional lymph node dissection would be reported separately in addition to 88309. A sentinel lymph node biopsy is not a component of a regional lymph node dissection, and the work in evaluating the sentinel lymph node is a distinct service. When a sentinel lymph node biopsy is accompanied by a lymph node dissection, both services are coded separately.

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Uterus, tubes, and ovaries

The codes for the uterus indicate they are “with or without tubes and ovaries.” The descriptors for ovary say they apply “with or without tubes.” This direction is intended to indicate that when the tubes and ovaries are removed incidentally to hysterectomy, or a tube is removed incidentally to ovarian resection, physician work is not increased significantly and only a single code is used, even if the surgeon places the organs in different containers. Thus, when a hysterectomy is performed for leiomyomata and the surgeon places tubes and ovaries with only incidental findings in separate containers, 88307 is reported once.

However, CPT treats ovaries and tubes as specimens coded separately from the uterus (Ovary, Non neoplastic 88305; Ovary, Neoplastic 88307; Fallopian Tube, Biopsy 88305) when separate evaluation is required and it is appropriate to code for evaluation of these organs. For example, when an ovary is removed because of a neoplasm and the uterus is also resected, the ovary is the primary specimen. Examination of the uterus is not included in the descriptor for evaluation of the ovarian neoplasm. Therefore, the separate evaluation of the uterus is coded based on the work involved (88307 for nonneoplasm or leiomyoma(s) or 88309 for neoplasm). An appendectomy done at the same time would be coded as 88302 for an incidental removal, 88304 for an abnormal appendix.

Although diagnosis does not affect coding of many services, it is important for some specimens, including these gynecologic evaluations, where CPT reflects differences in work examining neoplastic versus nonneoplastic conditions. Coding is based on the extent of the required evaluation considering both pathologic findings and clinical data. For example, a uterus with an endometrial carcinoma is coded as 88309 even though the clinical diagnosis preoperatively was leiomyoma. A uterus removed because of a history of carcinoma in situ is coded as an evaluation for neoplasm even if no residual neoplasm is present.

Twin placentas

Twin third-trimester placentas are subject to the same definition of specimen rules as other cases. If neither placenta is identified, there is one specimen and it should be coded as a single 88307. If one of the placentas is identified (for example, by a clamp on the cord), then there are two specimens and two 88307s should be reported.

Upcoding for malignancy or size

Unless specified in the surgical pathology code specimen listings, upcoding for malignant or other neoplastic diagnoses is not appropriate. Similarly, specimens listed in one code should not be upcoded because they are unusually large. For example, skin biopsies are to be coded 88305 whether they are seborrheic keratoses or melanomas. Prostate transurethral resections (TURs) are 88305, regardless of weight or number of blocks. Breast excisions requiring evaluation of margins are 88307 regardless of size.

Multiple-part LEEPs

Cervical loop electrical excisions (LEEPs) are sometimes submitted as separate specimens that are identified separately for orientation. The ectocervical portion of the LEEP excision should be coded like a cervical conization (88307). If it is submitted as separate specimens, then each should be coded as 88307 or 88305, depending on the work involved. Likewise, a separate endocervical specimen removed by LEEP should be coded as 88305 or 88307, depending on the work involved. Small endocervical samples are comparable to an endocervical biopsy or endocervical curettage (ECC) and 88305 is the appropriate code. A larger endocervical LEEP is comparable to a cervical conization and should be coded 88307.

Tissue recuts

The effort involved in recutting of tissue, such as when the specimen is folded in a critical area, should not be reported with a separate CPT code.

Special stains

Special stain codes (88312 to 88314) are used per stain, per specimen regardless of the number of slides stained. For example, one specimen with one special stain used on multiple slides receives the appropriate special stains code only once; however, one specimen that receives three special stains is coded separately for each special stain used.

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Consultations on referral

Consultations with reports on referred slides and material requiring preparation of slides (88321 and 88323) are frequently misinterpreted because the codes do not have the specimen as a unit of service. These codes are generally intended to refer to a single accession from another laboratory that might include multiple specimens. For example, a pathologist obtains prior mastectomy and colectomy specimens for comparison of different tumors with an FNA biopsy of a possible recurrence. Each would be coded separately. Slides from a radical hysterectomy with multiple specimens representing different lymph node groups or peritoneal samplings would be coded as a single consultation. The 88325 code is to be used with review of the patient’s chart, laboratory results, oncologist’s consultations, etc. It is not intended for use when review of the record is limited to pathology reports.

Fine-needle aspirations and core biopsies

Fine-needle aspirations are coded with the cytopathology 88170 to 88173 code series. Only one physician should code for each aspiration (CPT code 88170 or 88171); assistance by another physician is not separately codeable. The codes for immediate determination of adequacy (88172) and definitive interpretation (88173) also are to be reported per aspirate requiring separate evaluation as indicated by the CPT wording. For example, a pathologist examines an aspirate of a lung mass performed by a radiologist under radiographic guidance and identifies only benign pulmonary elements that would not explain the mass. A second aspirate is performed and the pathologist determines that this aspirate is diagnostic. The assessment of each aspirate is reported as 88172. A pathologist aspirates two areas of the thyroid in a patient with a diffusely enlarged gland and a large lower pole mass. Each aspiration would be coded as 88170 and each interpretation as 88173.

The 88172 code should not be used to report the assistance of a technologist during FNA-88172 is a physician service code. Code 88173 should be used to report all FNA definitive interpretations, whether a direct smear or a liquid-based slide preparation method is used.

Needle core biopsies should be coded 88305 or 88307, depending on the source. If there is an immediate determination of adequacy of the core biopsy using a cytological touch prep, code 88161 for the touch prep plus 88329 for the intraoperative consultation.

Concentration techniques

Interpretation of non-FNA, non-gyn cytopathology concentration techniques, such as liquid-based slide or cytocentrifuge preparations of pleural, lung or spinal fluid, are coded 88108 in addition to a direct smear when both are performed.

Use of modifier -59, distinct procedural service

Modifier -59 is used to indicate that a procedure or service is distinct or independent from other services performed on the same day by the same physician, laboratory, or other billing entity. It can be used to report services that might not ordinarily be separately billed but that are appropriate under the circumstances. This might occur when a specimen is from a separate site or surgery or a separate incision or aspiration, or is a service from a different session or patient encounter.

For example, when varicose veins are submitted for gross examination (88300) and a pigmented skin lesion is excised from the same patient on the same day (88305), the evaluation of the skin lesion includes both gross and microscopic examination and, therefore, you would not ordinarily report 88300 and 88305 for that evaluation. Modifier -59 can be used to indicate that the veins were a separate specimen. A similar situation occurs with consultation during surgery (88329). It would not usually be reported with a frozen section (88331) because 88331 includes the 88329.

However, if the pathologist is called several different times during surgery, it is appropriate to code for each distinct intraoperative consultation. One consultation could include a frozen section to establish a diagnosis of neoplasm. Later in the day the pathologist may be called to consult on margins of resection of the lesion which may not require frozen section or to perform a frozen section on a separate primary lesion or metastasis. In this situation, modifier -59 can be used with the second and any subsequent consultations. Medicare requires this use of the modifier for these codes.

An analogous circumstance occurs with fine-needle aspirations. The aspiration is reported as 88170 for a superficial lesion or 88171 for a deep lesion under radiologic guidance. If a superficial lymph node is aspirated and the same day a pulmonary nodule is aspirated, both 88170 and 88171 would be reported. Since both superficial and guided biopsies would not ordinarily be performed on the same lesion, modifier -59 can be used to indicate the biopsies are from separate lesions.

Carl Graziano is CAP TODAY Washington editor and CAP manager of government communications.

CPT is copyright 1998, American Medical Association. To purchase copies of CPT, contact the AMA at 800-621-8335.