Coding for pathologic evaluation of tissue from complex surgical procedures, such as a Whipple resection, involves appropriately reporting each specimen and service provided. However, coders must be cautious to avoid unbundling. |
Complex surgical specimens are especially susceptible to either underreporting or unbundling" " says R.M. Stainton Jr. MD president of Doctors' Anatomic Pathology Services an independent pathology laboratory in Jonesboro Ark. When the surgeon removes multiple organs or portions of organs pathology coders may struggle to identify accurately what constitutes the individual specimen which is the unit of service for surgical pathology.
Correct Coding for Surgical Pathology
The Whipple-type procedure involves the excision of various organs (or portions of organs) for the treatment of pancreatic cancer. The tissue removed may vary based on the surgeon's evaluation of the individual case. "In addition to the pancreas and duodenum tissue received from a Whipple resection might include the gallbladder the spleen a portion of the stomach the common bile duct lymph nodes and other tissues " Stainton says.
CPT defines the specimen (the unit of service for codes 88300-88309) as "tissue or tissues that is (are) submitted for individual and separate attention requiring individual examination and pathologic diagnosis." Coders are also told that "Two or more such specimens from the same patient are each appropriately assigned an individual code reflective of its proper level of service." CPT further states that "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."
Incorrectly applying these surgical pathology coding principles can cause either unbundling which could constitute fraud or undercoding which could result in sacrificing income for services rendered. "In the case of Whipple resections some pathologists believe that the pathologic evaluation should be reported as a single unlisted specimen to avoid the appearance of
unbundling " Stainton says. Others believe that reporting a Whipple evaluation as one service would amount to undercoding because it involves evaluation of one or more specimens listed in the CPT surgical pathology section.
The debate stems in part from vignettes developed for the National Study of Resource-Based Relative Value Scale for Pathologist's Services (Hsiao W.C. Ph.D. et al. Harvard School of Public Health 1991) that were used to formulate the current surgical pathology coding scheme introduced in CPT 1992. One vignette listed "gross and microscopic examination of a Whipples resection (gastriopancreoduodenectomy) for a mass in the head of the pancreas" as an 88309 (level VI - surgical pathology gross and microscopic evaluation). Based on this narrative some pathologists consider a Whipple resection to be an unlisted specimen reported as 88309.
"However reporting pathologic evaluation of a Whipple resection as an unlisted specimen when in fact the resection includes a varying number of listed specimens flies in the face of CPT coding principles for surgical pathology…………
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