Reprinted from July 1999 CAP TODAY
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 listscharge mastersthat 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,”
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
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
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,
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
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  or colectomy for
neoplasm with mesenteric lymph nodes ), 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 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.
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.
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
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
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.
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
CPT is copyright 1998, American Medical Association. To purchase copies
of CPT, contact the AMA at 800-621-8335.