Principles of CPT Coding in Surgical

Pathology
This section tries to provide a systematic, simple as much as possible, description of CPT coding
principles in the most controversial area in laboratory coding as surgical pathology. It also aims to
highlight common difficulties.
The CPT manuals Surgical Pathology subsection contains six major from 88300 through 88309 codes
(Levels I through VI). The Levels classification of codes increases in number as a reflection of the
relative difference in complexity of average physician work, although there is not consistency in this
regard.
The Surgical Pathology section of the voluminous official AMA CPT codebook lists 44 items. Only
about half of these are used with regularity by most pathologists and histology laboratories. The
section occupies only four pages in the CPT manual, but every sentence and even words have
significance, especially in the description part. Some notions are against medical logic and
disputable. They are discussed, however, to prevent a temptation for voluntary interpretations. The
AMA Manual is the law. Controversial issues will be mentioned just to show that they were thought
about, but rules of the game must be followed though some of the rules do not seem justified.
Let us dissect CPT definitions word by word and line by line, even separating sentences to clarify the
rules and nuances. The manuals text is presented in italic.
The unit of service for codes 88300 through 88309 is the specimen.
A specimen is defined as tissue or tissues that is (are) submitted for individual and separate attention,
requiring individual examination and pathologic diagnosis. Two or more such specimens from the same
patient (e.g., separately identified endoscopic biopsies, skin lesions, etc.) are each appropriately
assigned an individual code reflective of its proper level of service.
Both, the unit of service and specimen, are fundamental definitions in CPT coding in surgical
pathology, as the basic elements of charge.
A specimen is defined as tissue or tissues
According to Dorlands Medical Dictionary,
SPECIMEN- 1. A sample or part of thing, or several things, taken to show or to determine a character
of the whole, as a specimen of urine. 2. A preparation of tissue for pathological examination or of a
normal tissue, organ, or organism for study of its structure.
TISSUE an aggregation of similarly specialized cells united in the performance of a particular
function.
Relativity of CPT tissue/tissues definition as the specimens characteristic can be seen in some
examples. It is completely acceptable if heart valve and bone tissue, even a tooth or nail are in
consideration, but what about iron nail or heart valve prosthesis with or without attached soft tissue?
We can, however, cope with ambivalence of this CPT definition because it is difficult to suggest more
universal.
The CPT codebook pre-defines many commonly encountered surgical pathology specimens via a
list that appears under each code in the 88302-88309 series. This eliminates much of the guesswork
and subjectivity that might otherwise accompany the charge determination process. In general, a
specifically listed tissue cannot be classified outside the code category to which it is assigned in the
codebook.
Submitted for individual and separate attention, requiring individual examination and pathologic
diagnosis.
The pathologist expresses the chargeable attention only through a pathologic diagnosis which is
always individual though might have some collective efforts. Aside of inaccurate wording of this
description (separate means individual), there are practical implications.
It is understandable that every core in prostate biopsy requires individual separate attention, but five
cores in one container and one core in a different container are two specimens as far coding/charge
is concerned. The gallbladders neck lymph node also requires separate attention (it can be a
metastatic or lymphoma), but this is indisputably one specimen.
Two or more such specimens from the same patient (e.g., separately identified endoscopic biopsies, skin
lesions, etc.) are each appropriately assigned an individual code reflective of its proper level of service.
This portion of the CPT codebook guidance simply confirms that each separately identified and
diagnosed specimen is separately chargeable
Practice uses more than one code in one specimen, for example two codes bone marrow biopsy
88305 and 88311 (decalcification) or in Whipple procedure 88309 x 2, 3, 4. On the other side, practice
brings up new methodology, like in prostate needle biopsy saturation; a different set of coding
applies (for example, additional codes as G016- through GO19 for Medicare patients).
Service code 88300 is used for any specimen that in the opinion of the examining pathologist can be
accurately diagnosed without microscopic examination.
This code is a tricky for a surgical pathology department if there were not established intra
institutional set of policies. In this Level I category are two kind of specimens: a/ tissue that should
not even be send to pathology according to the institutional policy but for some reasons they have
been sent b/ specimens designated for gross only evaluation. More detail in special section GROSS
ONLY.
Service code 88302 is used when gross and microscopic examination is performed on a specimen to
confirm identification and the absence of disease.
This code is sometimes confusing because of the the absence of disease words that bring to life
temptation to change some initially applied codes as 88304 or 88305 in the case if a pathology has
not been revealed during gross and microscopic examination. In reality, codes 88302 are allocated to
situations where the CPT manual expects the absence of disease although scar, hernia is also some
pathology. At the same time, if during examination, the pathologist finds inflammation in the hernia
or appendix, it would not be right if the code were changed for higher Level, unless additional
examination (adds-on) were performed, but they are coded/charged separately anyway. 88302
code reflects procedural issue more than diagnostic issue.
Service codes 88304 through 88309 describe al other specimens requiring gross and microscopic
examination, and represent additional ascending levels of physician work. Levels 88302 through 88309
are specifically defined by the assigned specimens.
The justification of the coding Level selection should be in the pathology report, especially if for
some diagnostic and finding reasons the initial accession coding is changed. The rule is: not in the
report no charge.
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.
Every surgical pathology CPT code is billable both by a pathologist (professional component) and a
hospital (technical component). Nonetheless, the hospital and the pathologist might be independent
healthcare providers, so each should take sole responsibility for its own charges. Pathologists and
hospital or other TC provider can have different relationships, the goal of the support staff, namely
histotechnologists in charge for coding in this instance, to assure matching and consistency between
the Professional and Technical components.
Two main points that should be definitely underlined in the materials which have specific surgical
pathology practitioners interest:
First, although in the first sentence of the AMA manuals Introduction is unequivocally written that
Current Procedural Terminology is a set of codes, descriptions, and guidelines intended to describe
procedures and services performed by physicians and other health care providers, CPT manual
remarkably does not mentioned technical part. No histology hardship is involved, only physician
work. However, the term physician should not be taken literally. This term applies to all
practitioners eligible for CPT coding and ultimately billing.
Second, CPT assumes the average physicians work in the background of levels of complexity.
The main principle of CPT coding in surgical pathology is not applying fairness attitude but following
procedural logic with adherence to regulations of coding authorities, even if they seem illogical, and
honoring the commonly accepted practice. Compliance principle: if the point is written unequivocally
in the official documents follow even if it is against your understanding, the rest coding situations
should be grounded on the informed judgment.
The charge for services is the business part of health care. In every business there are more and less
profitable parts of work. Every respectable car repair shop would not during tire rotation charge extra
for a rusty bolt which require a great deal of efforts. Some specimens are time consuming and
apparently non-profitable. There can be reasons for some charge arrangements but they ought not
to interfere during CPT coding with certainty of the accessions surgical number as the filling entity,
the bedrock of specimen identification. There can be some revenue losses or unintentional even
overcharge. However, in big numbers amount of laboratory tests these occasions cannot be
sacrificed to traceable data of computer managed one specimen one container coding/charge.
Billing consideration cannot prevail on errors prevention measures that are related to patient safety.
As the last resort, there is a modifier 22, which rarely used. In general, the billing questions are out of
scope of this manual.
Perhaps, the coding authorities (AMAs CPT Advisory committee and CPT Editorial and Information
Services, as well as College of American Pathologists the Professional and Economic Affairs
Committee) will pay attention in formulation coding policies.
The practical application of the principles of CPT coding in surgical pathology will be presented in
case scenarios and comments to them in subspecialties. Everything should be done right from the
beginning to the end by informed choices when all participants (the accession person, the
pathologist, and the billing manager) speak the common language. The billing manager is the coder
expert, but others should professionally participate in the process with understanding what they are
doing. The materials provide recipes for similar situations. The goal is in streamlining of
understanding the CPT coding process without simplification, shortcut, and dumbed-down.