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Kelly Cashman, CPC

Anatomic Pathology Coding Review. Kelly Cashman, CPC. Kelly Cashman, CPC. 20+ years Medical Coding, Practice Management & Revenue Cycle Currently employed by Physicians Independent Management Services, Inc. (PIMS) 14+ years. Manager of team of 10 coders CPC February 2014 . Pathology.

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Kelly Cashman, CPC

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  1. Anatomic Pathology Coding Review Kelly Cashman, CPC

  2. Kelly Cashman, CPC • 20+ years Medical Coding, Practice Management & Revenue Cycle • Currently employed by Physicians Independent Management Services, Inc. (PIMS) 14+ years. • Manager of team of 10 coders • CPC February 2014

  3. Pathology Pathology is the study of all aspects of diseases. Anatomic Pathology is the subspecialty of pathology that pertains to the gross and microscopic study of organs and tissue removed from the body and the interpretation of the results of such studies. Cytopathology is the study of changes, at the cellular level, caused by disease. Surgical Pathology is the pathology of disease processes that are surgically accessible for diagnosis or treatment.

  4. Pathology Practices • Different Types Of Pathology Coding • Global Billing – No Modifier • Professional Component (PC) billing - Modifier 26 • Technical Component (TC) billing – Modifier TC • Different Types Of Pathology Practices • Independent Lab (IL) • Hospital Based Pathology Group (HBPG) • Physician Office Lab (POL)

  5. Professional (PC) and Technical (TC)Components Most pathology CPT codes have both a professional and technical component. Professional component (PC): billed by the physician who performs the professional component of the code (i.e. reads the slides) Technical component (TC): This is the amount that the lab/hospital charges to perform the service (i.e. making the slides)

  6. Independent Lab (IL) An independent laboratory is one that is independent both of an attending or consulting physician’s office and from a hospital. • Global Billing – lab performs both technical component & professional component and bills without a modifier • Professional Component - lab receives slides prepared elsewhere and provides the professional component. • Technical Component – lab performs technical component only and sends slides to be interpreted to another lab/pathologist.

  7. Hospital Based Pathology Group (HBPG) Hospital contracts with pathology group to provide pathology services to facility. • Includes Clinical & Anatomic Pathology. • Physician in HBPG can be Medical Director of Clinical Laboratory and listed on CLIA certificate. • Usually exclusive agreement to provide coverage & continuity

  8. Hospital Based Pathology Group (HBPG) Cont. from previous slide…. HBPG • Majority of the billing is Professional Component (PC) only: the 26 modifier. • Exception: CPT code is not PC/TC split code • Hospital bills for TC portion

  9. Physician Office Labs (POL) A laboratory maintained by a physician or group of physicians- performs diagnostic tests in connection with the physician practice. • Pathologist may be an employee of group or owner • Pathologist may be an Independent Contractor • Pathology work may be sent to IL for either TC or PC • Many different billing scenarios are possible

  10. Modifiers 26 – Professional component (PC) TC – Technical component 59 – Distinct procedural service 76 – Repeat procedure by same physician 77 – Repeat procedure by different physician 91 – Repeat clinical diagnostic laboratory test

  11. Surgical Pathology Surgical Pathology 88300-88399 • Surgical Pathology, gross and microscopic examination 88300-88309 • Per CPT, this family of codes includes the accession, examination, and reporting • Unit of service is each specimen (most of the time) • Carefully review your CPT Guidelines for this section

  12. Surgical Pathology

  13. Surgical Pathology 88300- Gross examination only • Specimen can be accurately diagnosed without microscopic exam. • No tissue blocks or slides are made 88302- G & M Level II, examples • Appendix, incidental • Fallopian tube, sterilization • Hernia sac, any location • Skin, plastic repair • Vas Deferens, sterilization

  14. Surgical Pathology 88304- G & M Level III examples: • Appendix, other than incidental • Bone fragment(s), other than pathologic fracture • Colon, colostomy stoma • Gallbladder • Hemorrhoids • Polyps, inflammatory- nasal/sinusoidal • Skin- cyst/tag/debridement • Tonsil and/or adenoids

  15. Surgical Pathology 88305- G & M Level IV examples: • Bonemarrow,biopsy • Breastbiopsy,notrequiringmicroscopic evaluationof surgical margins • Cellblock,anysource • Colon, biopsy • Extremity, amputation, traumatic • Kidney, biopsy • Lung, transbronchial biopsy

  16. Surgical Pathology 88305 examples (continued) – • Lymph node, biopsy • Nasal mucosa, biopsy • Ovary with or without tube, non-neoplastic • Polyp, colorectal • Prostate, needle biopsy • Skin, other than cyst/tag/debridement/plastic repair • Spleen • Tonsil, biopsy • Urinary bladder, biopsy • Uterus, with or without tubes and ovaries, for prolapse

  17. Surgical Pathology 88307- G & M Level V examples: • Bone – biopsy/curetting's • Bone fragment(s), pathologic fracture • Breast, excision of lesion, requiring microscopic evaluation of surgical margins • Colon, segmental resection, other than tumor • Extremity, amputation, non-traumatic • Kidney, partial/total resection • Liver, biopsy • Lung, wedge biopsy

  18. Surgical Pathology 88307 examples (continued) – • Ovary with or without tube, neoplastic • Prostate, except radical resection • Sentinel Lymph Node • Thyroid, total/lobe • Urinary bladder, TUR • Uterus, with or without tubes and ovaries, other than neoplastic/prolapse

  19. Surgical Pathology 88309- G & M Level VI examples: • Breast, mastectomy – with regional lymph nodes • Colon, segmental resection for tumor • Colon, total resection • Lung – total/lobe/segment resection • Prostate, radical resection • Urinary bladder, partial/total resection • Uterus, with or without tubes and ovaries, neoplastic

  20. Skin Specimens

  21. Breast Specimens

  22. GYN Specimens I

  23. GYN Specimens II

  24. Decalcification and Special Stains

  25. Immunohistochemistry (IHC)

  26. Pathology Consults

  27. Consultation on Outside Material

  28. Immunofluorescent (IF) and Electron Microscopy (EM)

  29. Non-Gynecology (Non-GYN) Cytology I

  30. Non-Gynecology (Non-GYN) Cytology II - FNA

  31. Flow Cytometry

  32. CASE STUDIESHOW WE MAKE IT HAPPEN see case studies hand-out

  33. 2014CODING CHANGES

  34. 2014 Immunohistochemistry Code (IHC) Changes CPT revision and addition of qualitative immunohistochemistry codes, effective January 1st, 2014. Revised code: 88342 - Immunohistochemistry or immunocytochemistry, each separately identifiable antibody per block, cytologic preparation, or hematologic smear; first separately identifiable antibody per slide New code:  88343 - Immunohistochemistry or immunocytochemistry, each separately identifiable antibody per block, cytologic preparation, or hematologic smear; each additional separately identifiable antibody per slide (List separately in addition to code for primary procedure)

  35. 2014 CMS IHC Code Change Per CMS, effective January 1, 2014, qualitative immunohistochemistry (CPT - 88342) is being replaced by • G0461(Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain) • G0462(Immunohistochemistry or immunocytochemistry, per specimen; each additional single or multiplex antibody stain).

  36. cont. from previous slide…. Please note reimbursement impact: • 88342-PC CMS 2013 reimbursement - $42.36 • G0461-PC CMS 2014 reimbursement - $30.81 • G0462-PC CMS 2014 reimbursement - $12.56 • Clinical examples with CPT code assignment and reimbursement comparisons.

  37. Clinical Example #1Non-Medicare Medicare • Specimen A: Retroperitoneal mass • Block A1 • Slide 1: IHC primary stain for CD-20 88342 G0461 • Slide 2: IHC primary stain for PAX-5 88342 G0462 • Slide 3: IHC primary stain for BCL-6 88342 G0462 • Slide 4: IHC primary stain for CD45 88342 G0462 • Block A2 • Slide 1: IHC primary stain for CD20 88342 N/C • Slide 2: IHC primary stain for CD15 88342 G0462 • Slide 3: IHC primary stain for CD30 88342G0462 • Total $296.52 Total $93.61

  38. Clinical Example #2 Non-Medicare Medicare • Specimen B: Sentinel lymph node, right • Block B1 • Slide 1: IHC primary stain for AE1/AE3 88342G0461 • Slide 2: IHC primary stain for AE1/AE3 N/CN/C • Block B2 • Slide 1: IHC primary stain for AE1/AE3 88342 N/C • Slide 2: IHC primary stain for AE1/AE3 N/CN/C • Specimen D: Sentinel lymph node, left • Block D1 • Slide 1: IHC primary stain for AE1/AE3 88342 G0461 • Slide 2: IHC primary stain for AE1/AE3 N/CN/C • Total $127.08Total $61.62

  39. Clinical Example #3 Non-Medicare Medicare • Specimen A: Skin biopsy, melanoma vs. nevus • Block A1 • Slide 1: IHC primary stain for HMB-45 88342G0461 • Slide 2: IHC primary stain for Tyrosinase 88342 G0462 • Slide 3: IHC primary stain for S100 88342 G0462 • Slide 4: IHC primary stain for Melan-A/Ki67 88342G0462 • Total $169.44 Total $68.49

  40. Clinical Example #4 Non-Medicare Medicare • Specimen B: Prostate needle biopsy, right 2 • Block B1 • Slide 1: IHC primary stain for PIN-488342 G0461 • 88343 x 2 • Specimen J: Prostate needle biopsy, left 4 • Block J1 • Slide 1: IHC primary stain for PIN-488342 G0461 • 88343 x2 • Total $127.08 Total $61.62

  41. 2014 CMS Prostate Code Change G0416 Per CMS, effective January 1, 2014, prostate cases with 10 or more biopsies must be billed using G0416 (Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 10-20 specimens) regardless of biopsy procedure (needle/incisional/saturation). Please note reimbursement impact: • 88305-PCx12 CMS reimbursement - $440.88 • G0416-PCX1 CMS reimbursement - $183.57

  42. Resources College of American Pathologists www.cap.org STATLINE http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt{actionForm.contentReference}=statline%2Findex.html&_state=maximized&_pageLabel=cntvwr#Story3 American Medical Association http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page American Pathology Foundation www.apf.org The Coding Institute http://www.codinginstitute.com/

  43. KELLY CASHMAN, CPC • PHYSICIANS INDEPENDENT MANAGEMENT SERVICES, INC. WWW.PIMS-INC.COM 5755 HOOVER BLVD., TAMPA, FL 33634 813. 886.8334 PHONE 813.886.6655 FAX kcashman@pims-inc.com

  44. Thank you for your kindness and attention

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