Anatomical pathology brings approximately 10 percent of the pathology department’s revenue, but it—especially surgical pathology—is the most vulnerable area in current procedural terminology (CPT) coding in a facility with high volume of specimens and diversified surgical activity. Although soft tissue tumors are relatively rare, they are often the source of confusion and mistakes in surgical pathology CPT coding.
The First Step
“Preventing Unintentional Overcharge” (ADVANCE for Administrators of the Laboratory, August, 2004) and the “Accession, Coding” link on the Web site “Grossing Technology in Surgical Pathology” (www.grossing-technology.com) discuss objective and subjective reasons for incorrect CPT coding in surgical pathology. Nevertheless, correct coding is possible if one follows the letter and spirit of AMA’s CPT coding manual. The correct initial code is the first step for complicated fee calculations, otherwise everything goes wrong.
Case in Point
The following case studies and examples present clinical coding situations that might be a source of mistakes. All cases are the simulated learning material. As a realistic fiction, they reflect typical clinical coding scenarios in different institutions.
Each specimen is evaluated by the American Medical Association (AMA) CPT coding manual’s code level for surgical pathology following a similar format. The first column presents the accession–technical bill (the technical component service, TC); the second reflects the sign out–professional bill (the professional component, described with modifier 26). The corrected code is marked with the credit symbol .
Three main CPT code denotations for surgical pathology represent soft tissue tumors:
- 88304 Level III — Soft tissue, lipoma.
- 88307 Level V — Soft tissue mass (except lipoma)–biopsy/simple excision.
- 88309 Level VI — Soft tissue tumor, extensive resection.
Other denotations such as “mediastinum, mass, ” “odontogenic tumor” and “leiomyoma(s), uterine myomectomy—without uterus, ” are rarely the source of mistakes.
Lipoma
Traditionally, lipomas are the realm of dermatopathology unless they are not excised from deep areas in the body as soft tissue tumors. If the requisition form includes lipoma diagnosis, the accession is easy and correct. However, the ubiquitous “mass” appears in most cases. Actually, “mass” describes almost everything from a cyst to a nodule. The catch is that “soft tissue mass (except lipoma)” is Level V 88307. Some computer dictionaries include “mass” Level V, as a separate denotation. This notorious “mass” is often culprit for overcharge mistakes, especially in lipoma cases.
Some examples illustrate the most common clinical situations:
- Technical bill Professional bill
- Example #1: Mass upper back, Lipoma Level III
- punch biopsy Level V
- Example #2: Right wrist, mass Lipoma Level III
- excision Level V
The pathologist or billing manager should catch this mistake, but often it goes unrecognized. Other difficult situations include:
- Technical bill Professional bill
- Example #3: Mass of forearm, Angiolipoma Level V
- excision Level V
- Example #4: Skin right upper Myxolipoma Level V
- flank mass Level V
Both examples can be considered as “soft tissue mass” Level V 88307 although they have the lipoma diagnosis. The interpretation of them as Level V “real” soft tissue tumor excision is very much defensible.
Soft Tissue Mass–Biopsy/Simple Excision
This denotation is not the best in the CPT manual. Besides being the trigger of confusing “mass” in the computer dictionaries, it includes the ambiguous “simple excision” definition.
There is no problem with biopsies, although it is unclear why soft tissue mass/nodule is Level V 88307 when biopsy of a breast mass/nodule/lump biopsy is Level IV 88305. Some computer dictionaries consider soft tissue mass biopsy as Level IV 88305 just to be on the safe side.
Actually, the definition “mass” is a temporary substitute for the word “tumor” and specifically what kind in the final pathology report. The “mass” or “tumor” should disappear after the sign out. The pathologist/compliance officer/billing manager’s aim is making corrections, if any, in the accession/technical bill.
Case #1
A 72-year-old male underwent an excision of an irregular form lump 4x3x2.5 centimeters in the right subscapular area with a fragment of fibroadipose tissue in the right axillary region, presumably a lymph node.
- Technical bill
- Specimen #1 Soft tissue tumor, right back, excision
- Level VI 88309
- Specimen #2 Lymph node, right armpit Level V 88307
- Professional bill
- Specimen #1 Elastofibroma, excised completely, Level V 88307
- Specimen #2 Two lymph nodes, benign, Level IV 88305
This case represents denotation of soft tissue mass, simple excision Level V. Although two lymph nodes were found in the fragment of adipose tissue, by essence, a biopsy had been performed that is “lymph node, biopsy” Level IV 88305.
Elastofibroma is a rare soft tissue tumor, but this case is typical as far as correct CPT coding is concerned. Other benign soft tissue tumors, as fibroma, fibrous hemartoma, histiocytoma, etc., can be coded similarly.
Some examples illustrate scenarios that should be discussed. The accession code should be changed after sign out.
- Technical bill Professional bill
- Example #5: Skin lesion, Hemangioma, full excision, excision Level IV Level V
- Example #6: Interdigital mass left Morton’s neuroma, foot , excision, Level V excision, Level III
- Example #7: Scar, mastectomy Scar tissue, no evidence
- Level II of malignancy
- Level V
Hemangioma, as a soft tissue tumor, was removed by simple excision that is Level V 88307. Morton’s neuroma, a variant of traumatic neuroma, is Level III 88304, as is stated unequivocally in the CPT manual “Neuroma-Morton’s/Traumatic.”
Although a scar is coded as “skin, plastic repair,” in this situation, the scar requires a definite excision and meticulous examination to exclude malignancy closer to code “soft tissue mass, simple excision” Level V 88307.
Soft Tissue Tumor, extensive resection
Cases of extensive resection of soft tissue tumors are not difficult for coding, but some details are worth mentioning. Often soft tissue tumor’s resection can include surrounding areas that should be examined and coded.
Case #2
A 57-year-old woman underwent a right chest resection due to a round lump 7x6x5 centimeters. The resected portion of the chest wall included three ribs. A fragment of a right lung 4x2x1 centimeters also was resected, as well as a nodule-like adipose tissue of the right axillary area.
Technical bill
- Specimen #1: Right chest wall Level IV 88305
- Specimen #2: Right upper lobe Level VI 88309
- Specimen #3: Right axillary lymph nodes Level V 88307
Professional bill
- Specimen #1: Intramuscular lipoma, present at resection margins, bone, and intercostal muscle Level VI 88309, Decalcification 8311
- Specimen #2: Lung, wedge resection, no evidence of malignancy Level V 88307
- Specimen #3: Lymph node, no evidence of malignancy Level IV 88305
Specimen #1 definitely deserves the Level VI code due to intensive resection, although the diagnosis remains in the lipoma category. It required differential diagnosis with well-differentiated liposarcoma and the determination of the bone involvement. Disbundling the bone part of the specimen–bone resection–would be disputable, but the decalcification code is completely justified.
Specimen #2 was overcharged as lobe resection because it was a lung wedge resection, though not for diagnostic purpose. Level V is the appropriate code in this case.
Specimen #3 was accessioned as regional resection although it was a diagnostic lymph node biopsy.
Unfair Coding
Usually, the coding in extensive soft tumor resection is correct. Sometimes problems occur in bundling/unbundling questions. In general, these time-consuming specimens, as a result that the tumor is removed in block, are coded/charged unfairly because they require enormous clinical and pathology work.
Malignant melanomas are the realm of dermopathology, but in the case of metastases in soft tissue or repeated surgery with wide skin excision, melanomas belong to “Soft Tissue Tumor, Extensive Resection” as far as coding is concerned. These cases should be coded as Level VI 88309.
Final Thoughts
The presented examples and case studies encompass the most clinical coding scenarios that can be difficult for correct evaluation. The involvement of the signing out pathologist and understanding of medical coding issues by the billing manager can prevent loss of revenue and, especially, overcharge.
