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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. STUDY CASE # 1 - CYTOLOGY INTERESTING LAB LLC 101 Beautiful St. Pomona, CA 88305 CYTOLOGY REPORT Patient Name: Vector, James DOS: 5/6/14 SPECIMEN 1: BLADDER, WASHING MICROSCOPIC DIAGNOSIS: Positive for malignancy. Consistent with urothelial carcinoma/carcinoma in situ. See also biopsy report 1REL-14-00585. SCREENED BY DWR. GROSS DESCRIPTION: Received are 60 cc of red fluid; one ThinPrep and one cell block are prepared. zm/zm COMMENTS Case reviewed in conjunction with Dr. O’Neill who concurs with the above diagnosis. CPT: 88112, 88305 ****Electronically signed by Ali Sheperd, M.D.**** END OF REPORT

  33. STUDY CASE # 2 – FINE NEEDLE ASPIRATION (FNA) • INTERESTING LAB LLC • 101 Beautiful St. • Pomona, CA 88305 • CYTOLOGY NON-GYN REPORT • Patient Name: Vector, James DOS: 5/6/14 • Final Diagnosis • Subcarina, fine needle aspiration biopsy: One thin preparation, one cell block, six Diff-Quik stained and four Papanicolaou stained smears are available for review. • Diagnostic category: Malignant. • Diagnosis: Poorly differentiated adenocarcinoma present. See comment. • Adequacy: Satisfactory for evaluation. • Comment • Immunohistochemical stains, performed with adequate controls on the cell block, show the carcinoma cells to be positive for CK7 and Napsin, focally positive for TTF-1 and CK5/6, and negative for p63 and CK20, supporting the diagnosis. • Page 1 of 2

  34. STUDY CASE #2 – FINE NEEDLE ASPIRATION (FNA)(cont.) • CYTOLOGY NON-GYN REPORT • Patient Name: Vector, James DOS: 5/6/14 • Specimen(s) Received • 1 Subcarina  • Clinical Information • Pre-op diagnosis: Lung mass • Post-op diagnosis: None given • Clinical History: Chest pain • Gross Description • Received are four alcohol-fixed smears for Papanicolaou stain and six Diff-Quik stained smears, and approximately 35 cc of pink, cloudy fluid fixed in CytoLyt which are submitted to Reliance. One ThinPrep and one cell block are additionally prepared and screened. • 5/5/2014 • Intraoperative Consultation • Preliminary impression regarding specimen adequacy per Dr. Sheperd. “Cells present suspicious for non-small cell carcinoma”. • CPT code: 88172, 88173, 88305, (88342 x 6 or G0461 and G0462x5) • ****Electronically signed by Ali Sheperd, M.D.**** • END OF REPORT

  35. STUDY CASE #3 – Flow Cytometry

  36. STUDY CASE #3 – Flow Cytometry (cont.)

  37. STUDY CASE #4 – FEMORAL HEAD PATHOLOGY REPORT Patient Name: Vector, James DOS: 5/6/14 SPECIMEN A, RIGHT FEMORAL HEAD COMPONENTS MICROSCOPIC DIAGNOSIS: “RIGHT FEMORAL HEAD”: FEMORAL HEAD WITH EBURNATION OF ARTICULAR CARTILAGE, AND FOCAL INTRAMEDULLARY HEMORRHAGE, CONSISTENT WITH FRACTURE. GROSS DESCRIPTION: The specimen is received in formalin labeled with the patient’s name and “right femoral head components” and consists of a fragmented, 5.0 x 4.5 x 4.0 cm femoral head which has a jagged, irregular, hemorrhagic bone resection margin. The cortical bone, articular surface is tan and smooth. Within the container is a 1.4 cm length of femoral neck which has one flat cut bone resection margin, and an opposing jagged, hemorrhagic irregular margin. The medullary bone is mottled from tan-red to tan-yellow and a tan articular rim ranges from 0.1 cm to 0.2 cm. A representative section from the jagged, hemorrhagic bone resection margin is submitted in one cassette, following decalcification. ****Electronically signed out**** Ali Shephard, M.D. CPT: 88305, 88311

  38. STUDY CASE #5 - RENAL INTERESTING LAB LLC 101 Beautiful St. Pomona, CA 88305 SURGICAL REPORT Patient Name: Vector, James DOS: 5/6/14 Clinical History 37-year-old female with history of systemic lupus erythematosus is being evaluated for nephrotic range proteinuria and microscopic hematuria. Positive anti double stranded DNA, low C3 and C4. Creatinine 0.6. Urinalysis 10-20 WBCs, 30-50 red blood cells, ANA positive, 1:2560 homogeneous. Lupus anticoagulants negative. C3 21, C4 3.6, positive SSA. Positive Sm. Lupus diagnosis was made a few months ago and the patient has been treated with Prednisone and Plaquenil. Hematuria. Specimen(s) Received RIGHT KIDNEY BIOPSY Final Pathologic Diagnosis Needle biopsy of right kidney: Lupus nephritis. WHO Class III (B). ISN/RPS Classification: Class III-S (A/C). Minimal interstitial fibrosis and tubular atrophy. PHYSICIAN NOTIFICATION: The findings were discussed with Dr. Jones on 5/7/14. Dr. Smith was also notified at 4:30 p.m. on 4/10/14. ****Electronically signed by Ali Sheperd, M.D.**** page 1 of 3

  39. STUDY CASE #5 – RENAL (cont.) • INTERESTING LAB LLC • 101 Beautiful St. • Pomona, CA 88305 • SURGICAL REPORT • Patient Name: Vector, James DOS: 5/6/14 • Gross Dictation • The specimen is retrieved fresh from CT by Dr. Picantie, labeled with the patient’s name and are three 0.1cm in diameter cores of tan tissue, 2.6 cm, 3.0 cm, and 3.1 cm. The specimen is submitted entirely as follows: • One 0.3cm in length core for electron microscopy, two cores (0.3 cm and 0.4 cm) for immunofluorescence studies and the remaining tissue (1.0 cm, 1.6 cm, 2.0 cm and 2.8 cm) for light microscopy in cassette KID. • INTRAOPERATIVE CONSULTATION: Adequate. Dr. Picantie • Intraoperative Consult Diagnosis • Adequate. Dr. Picantie • Microscopic Description • LIGHT MICROSCOPY (STAINS: H&E, PAS, PAMS, and MT): This biopsy is adequate and representative and consists of portions of cortex and medulla. At multiple levels, up to about 47 glomeruli are identified. Most of the glomeruli reveal mild mesangial expansion, predominantly with excess matrix and focally with slight increase in cellularity in some segments. In about 10 glomeruli, there is segmental architectural alterations with focal capillary luminal obliteration secondary to mesangial interposition and infiltration of leukocytes. There is minimal focal karyorrhexis but no evidence of fibrinoid necrosis. A rare segment shows adhesion to the capsule. Focal fibrosis is highlighted by Trichrome stain. • page 2 of 3

  40. STUDY CASE #5 – RENAL (cont.) • INTERESTING LAB LLC • 101 Beautiful St. • Pomona, CA 88305 • SURGICAL REPORT • Patient Name: Vector, James DOS: 5/6/14 • Interstitium exhibits a few scattered foci of lymphocytic infiltration with associated focal mild interstitial fibrosis and tubular atrophy. The overall interstitial fibrosis and tubular atrophy is less than 2% of the examined cortex. The rest of the tubules are of normal size and morphology. The interlobular arteries are within normal limits. There is no microangiopathy or vasculitis. • DIRECT IMMUNOFLUORESCENCE: • H&E stained slides of the frozen section reveal a portion of renal cortex including up to about 8-10 glomeruli in different levels. 1+ granular peripheral capillary wall staining with focal mesangial staining is noted in for IgG (1+ in 4 glomeruli), C3 1+ in 6 glomeruli, Kappa (trace) in 5 glomeruli, Lambda 1+ in 6 glomeruli and C1q 1 to 2+ in 6 glomeruli. IgA, IgM, Fibrinogen and Albumin are negative. • ELECTRON MICROSCOPY: • Three blocks are prepared. Two glomeruli examined reveal multiple segments exhibiting small and medium-sized mesangial electron dense deposits and several subendothelial immune complex deposits. There are no epimembranous deposits. Mesangial interposition with duplication of basement membrane is identified focally. There are also scattered intraluminal leukocytes. A few foci of architectural disarray is noted with near total capillary luminal obliteration secondary to excess matrix, immune complex deposition and basement membrane disarray. Podocytes reveal a few foci of foot process simplification and effacement. • CPT: 88305, 88313 x 3, 88329 x 1, 88346 x 9, 88348 • END OF REPORT

  41. STUDY CASE #6 – BONE MARROW • INTERESTING LAB LLC • 101 Beautiful St. • Pomona, CA 88305 • SURGICAL REPORT • Patient Name: Vector, James DOS: 5/6/14 • Clinical History • Bone depression to rule out bone marrow disorder. • Specimen(s) Received • BONE MARROW BIOPSY AND CLOT • Final Pathologic Diagnosis • THROMBOCYTOPENIA AND ANEMIA. • NORMOCELLULAR BONE MARROW WITH TRILINEAGE HEMATOPOIESIS. • ADEQUATE NUMBER OF MEGAKARYOCYTES. • Comment: The above findings are most consistent with the diagnosis of ITP. • Gross Description • The specimen is received in formalin labeled with the patient’s name and is a 1.0 cm in length x 0.2 cm in diameter core of tan to red-tan bone, with a 2.5 x 1.6 x 0.4 cm rectangular portion of red-brown clot. The specimen is submitted entirely as follows: • BM1) Bone core prior to decalcification. • BM2) Clot. • The procedure was performed by Dr. Ali Sheperd. • ****Electronically signed by Ali Sheperd, M.D.**** • page 1 of 3

  42. STUDY CASE #6 – BONE MARROW • INTERESTING LAB LLC • 101 Beautiful St. • Pomona, CA 88347 • SURGICAL REPORT • Patient Name: Vector, James DOS: 5/6/14 • Microscopic Description • PERIPHERAL SMEAR • The red cells exhibit mild poikilocytosis with nucleated forms. The hemoglobin is 10.3 grams percent with an MCV of 77. The white count is 4700 with an automated differential of 55% polys, 39% lymphocytes and 6% monocytes. Atypical cells are not observed. The platelet count is 19,000. • BONE MARROW ASPIRATE: • The aspirate is cellular and adequate for evaluation. The differential consists of 2% blasts, 14% myelocytes, 15% metamyelocytes, 14% bands, 8% polyps, 21% lymphocytes and 26% normoblasts. Megakaryocytes are identified. Atypical cells are not observed. • BONE MARROW CLOT: • Marrow cellularity approximates 50%. Myeloid and erythroid cells are present in usual numbers. Moderate number of neutrophils are noted. Clusters of atypical lymphoid cells are not observed. Megakaryocytes are in their usual numbers with normal morphology. Granulomata and tumor cells are not present. An iron stain demonstrates absent iron stores. • BONE MARROW BIOPSY: • Bony trabeculae are unremarkable. The marrow cellularity approximates 50%. Blood vessels are normal. No evidence of granulomata or tumor. Megakaryocytes appear in usual numbers. • CPT: 38220, 38221, 85097, 88305 x 2, 88311, 88313

  43. STUDY CASE #7 – GASTROINTESTINAL SPECIMEN INTERESTING LAB LLC 101 Beautiful St. Pomona, CA 88305 ANATOMIC PATHOLOGY REPORT Patient Name: Vector, James DOS: 5/6/14 SPECIMEN A, GASTRIC, BIOPSY MICROSCOPIC DIAGNOSIS: STOMACH, BIOPSY: PORTIONS OF SUPERFICIAL GASTRIC MUCOSA, ANTRAL AND FUNDIC TYPES, WITH MILD CHRONIC GASTRITIS. DIFF-QUIK STAIN FOR HELICOBACTER IS NEGATIVE. PLEASE SEE COMMENT. COMMENT: THE HISTOLOGIC FEATURES OF THIS GASTRITIS ARE SUGGESTIVE OF A CHEMCIAL TYPE GASTRITIS AS WOULD BE SEEN WITH THE USE OF NON-STEROIDAL ANTI-INFLAMMATORY DRUGS, ALCOHOL, OR WITH BILE REFLUX. CLINICAL CORRELATION IS SUGGESTED. GROSS DESCRIPTION: The specimen is received in formalin, labeled with the patient’s name and “gastric biopsy” and consists of two tan portions of soft tissue which are each 0.3 cm in greatest dimension. Both portions are submitted in toto in cassette A1. SPECIMEN B, ESOPHAGUS, BIOPSY MICROSCOPIC DIAGNOSIS:ESOPHAGUS, BIOPSY: PORTIONS OF SQUAMOUS MUCOSA WITH BASAL CELL HYPERPLASIA, SUGGESTIVE BUT NOT DIAGNOSTIC OF GASTROESOPHAGEAL REFLUX. AN ALCIAN BLUE/PAS STAIN DIES BIT REVEAL FUNAL ORGANISMS. GROSS DESCRIPTION: The specimen is received in formalin labeled with the patient’s name and “esophageal biopsy” and consists of two tan-gray portions of soft tissue which are 0.2 cm and 0.3 cm in greatest dimension. Both portions are submitted in toto in cassette B1. CPT: 88305 x 2, 88312 x 2 ****Electronically signed by Ali Sheperd, M.D.****

  44. 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)

  45. 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).

  46. 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.

  47. 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

  48. 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

  49. 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

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