CPC Chapter 18

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Chapter 18 Pathology and Laboratory Introduction In this chapter, we will discuss CPT®, ICD-10-CM, and HCPCS Level 11 codes related to pathology and laboratory services. These services apply to all parts of the body and nearly all disease processes and are defined by the process used to perform the service, or by the substance analyzed (the analyte). Most codes have both professional and technical components. [CD-10-CM codes may come from nearly any chapter. We will focus on codes most specific to testing. We will cover some of the rules for assigning codes, rather than providing a comprehensive overview of codes. Some HCPCS Level 11 codes are used for specific services; we will address these also. The objectives for this chapter Include: ¢ Define terms and concepts specific to pathology and laboratory coding e Apply ICD-10-CM guidelines when assigning codes for diagnostic services and identify specific codes helpful in describing the medical necessity and outcomes of specific lab tests e Select CPT* and HCPCS Level Il codes describing the services and procedures for pathology and laboratory services e Apply CPT® and HCPCS Level Il modifiers, when appropriate Terminology Services related to pathology and laboratory have their own terminology built on the same root words, prefixes, and suffixes discussed in other chapters, with a few terms unique to these diagnostic services. Pathology is the study of diseased tissue and cells (path/o = disease, -logy = study of ). Pathology services include necropsies or autopsies, which are examinations of dead bodies to determine the cause(s) of death. Cytopathology is the study and diagnosis of diseases on a cellular level (cyt/o = cell). Cytogenetics goes one step further to study the genes within the cells to determine whether diseases have inherited components and to identify the specific genetic components of certain disease processes. Laboratory, in this context, refers to tests performed primarily in a medical laboratory (also called a clinical laboratory). Tests of clinical specimens provide information for the diagnosis, treatment, and prevention of disease. Molecular diagnostics is the measurement of deoxyribonucleic acid (DNA), ribonucleic acid (RNA), proteins, or metabolites to detect genotypes, mutations, or biochemical changes. Hematology is the study of the components and behavior of blood (hemat/o = blood). Immunology is the study of the immune system and its components and function. Microbiology (micr/o- = small, bi/o = life) includes four subspecialties: bacteriology (study of bacteria), mycology (study of fungi), parasitology (study of parasites), and virology (study of viruses). Many Pathology and Laboratory CPT® codes (80047-80076) describe a panel of tests. When a panel code is used, each test listed in the panel description must be performed. Do not report two or more panel codes that include the same tests. For example, 80047 is not reported with 80053 because they both include many of the same tests. Separately report tests not included in the main panel. Tests may be identified as quantitative or qualitative. Qualitative testing determines the presence or absence of a drug only. Quantitative testing identifies not only the presence of a drug, but the exact amount present (quantitative shares the same root word as quantity). For example, a patient is brought to the ED after an auto accident. If there is suspicion the individual has been drinking, a qualitative test might be performed to confirm the presence or absence of alcohol in the bloodstream. If alcohol is detected, a separate quantitative test is needed to determine the quantity of alcohol involved. Tests also may be semi-quantitative. Semi-quantitative tests describe an amount within a specified range or over a certain threshold, but do not identify a specific quantity. Gross examination (for example, 88300) is examination of the entire specimen without sectioning of the specimen into slides for examination under a microscope. Microscopy (88302-88309) is examination of a specimen under a microscope. All pathology codes for microscopic examination also include gross inspection. The word forensic refers to studies used or applied in the investigation and establishment of facts or evidence in a court of law. The Latin term in vivo refers to studies performed “within the living body” The Clinical Laboratory Improvement Amendments (CLIA) passed in 1988 establishes quality standards for all laboratory testing. It ensures the accuracy, reliability, and timeliness of patient test results regardless of where the test is performed. Diagnostic test systems are placed into one of three CLIA regulatory categories based on potential for risk to public health: waived tests, tests of moderate complexity, and tests of high complexity. Any lab or clinic performing any diagnostic test must have a CLIA number. This number certifies the complexity of tests to be performed in the testing location. No diagnostic tests should be performed (whether billed or not) without a CLIA certificate. All bills for tests must include the CLIA number of the testing location. Certificates for waived tests can be issued by application, without any inspection. Certificates for more complex testing require inspections, calibration of equipment and other tests to assure the quality and accuracy of tests performed. Key Root Words for Pathology and Laboratory Coding Bacten/o bactena Micro- small Bi/o iife Myc/o fungus, mold Cyt/o cell Parasit/o parasite Gen/o gene Path/o disease Hemat/o blood Vir/o virus Immun/o IMMmuNe, Immune system

Chapter 18: Pathology and Laboratory Section Review 18.1 s The word “pathology” refers to the study of which of the following? A. Deterioration B. Direction C. Disease D Distress Answer: C. Disease Rationale: The root word path means “disease.” The suffix -logy is “study of” 2. Which word describes the study of small life forms? A. Hematology B. Immunology C. Invivo D. Microbiology Answer: D. Microbiology Rationale: The root words micro (small) and bio (life) combined with the suffix -logy describe the study of small life forms. 3. Which term is used with the word pathologist to describe someone specializing in legal or investigational studies? A. Invivo B. Forensic C. Laboratory D None of the above Answer: B. Forensic Rationale: The word forensic refers to information related to an investigation of legal matters. A forensic pathologist examines specimens for causes of disease or death related to legal matters. 4. A test determining the presence or absence of a substance is considered what type of test? A. Qualitative B. Quantitative C. Forensic D. Hematologic Answer: A. Qualitative Rationale: A qualitative test determines the presence or absence of the substance. 5. If a patient has a test result indicating a blood alcohol level of .05, what type of test was performed to determine this information? Microbiology B. Qualitative C. Quantitative D. Urine dip test Hide Answer » Answer: C. Quantitative Rationale: A quantitative test determines the amount of a substance found in the specimen. A qualitative test determines the presence or absence of the substance.

Chapter 18: Pathology and Laboratory ICD-10-CM Pathology and Laboratory studies identify infectious and parasitic diseases, presence and morphology of neoplasms, quantities of various naturally occurring substances in various bodily fluids and other tissue, pregnancy status, hormonal changes, and many other factors about health and disease. Almost any code in any chapter of ICD-10-CM can be appropriate as an indicator for a test or finding. In this section, we will look at the rules for assigning ICD-10-CM codes based on medical necessity and diagnostic findings. We will discuss specific codes to use when findings are inconclusive or negative/normal. Assigning ICD-10-CM Codes for Diagnostic Services When a provider orders a laboratory test or pathologic examination, a reason for the order must be reported. This reason is the medical necessity for the service. Common reasons to order a test include: » Screening—There are no indications of disease or personal or family history indicating a disease or disorder exists, but a study is performed to check for evidence of disease. » Signs and/or symptoms—There are indications the patient may have a disease process and further study is needed to identify the specific disease or other causes of the symptoms. ¢ Previous abnormal finding—The patient had a previous test indicating some abnormality, but it was not diagnostic of a specific disease. The finding must be rechecked, or the patient must be followed for any changes to the finding. o Current disease—The patient has an active disease to be followed for worsening symptoms or improvement. * Personal or family history of disease—The patient or members of the patient’s family had a disease, and the patient needs to be checked for personal recurrence or manifestation of a hereditary disease. Itis critical to code as precisely as possible the reason the test or study is ordered. If a patient’s test or study returns a more specific diagnosis than was known at the time the study was ordered, the findings of the test are coded rather than the reason the test was ordered. 1. Ayoungman is planning to get married. He and his fiancée have agreed to get human immunodeficiency virus (HIV) tests prior to their wedding. He has no symptoms or reason to think he has the disease. Report the first test with Z11.4 Encounter for screening for HIV. If the test is negative, this is the only code used. If the test results come back indicating an abnormality, report R75 Inconclusive laboratory evidence of HIV. If the test results come back positive for HIV exposure without clinical manifestations (no symptoms), report code Z21 Asymptomatic HIV infection status. This code is reported until the patient develops symptoms of acquired immune deficiency syndrome (AIDS), at which time code B20 is reported for the remainder of the patient’s life. 2. A middle-aged woman presents for her annual physical exam and Papanicolaou (Pap) smear. She has no symptoms of disease. When the first test is ordered, report Z12.4 Encounter for screening for malignant neoplasm of cervix. If the test is negative, this is the only code reported. If the test results come back indicating an abnormality, assign a code from category R87 Abnormal findings in specimens from female genital organs. Choose the most specific information known from the Pap smear report. If further testing is negative (or continues to be inconclusive), this is the only code reported. If the test results come back positive for cancer or cervical hyperplasia or another condition, choose the appropriate code for the condition based upon the diagnosis described in the Pap smear report. Always code to the highest degree of certainty. Never code “possible;” “rule out,” or “exclusion” diagnoses; instead, code the sign or symptom indicating the reason the test was ordered. If a more specific diagnosis is confirmed by the test, code for the test result rather than the indications for the test. If test results are inconclusive, code for abnormal findings. Abnormal Findings In ICD-10-CM, Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99), codes R70-R79 are for Abnormal findings on examination of blood, without diagnosis. R80-R82 Abnormal findings on examination of urine, without diagnosis; R83-R89 Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis; R90-R94 Abnormal findings on diagnostic imaging and in function studies, withour diagnosis; and category R97 Abnormal tumor markers may be used as either the reason (medical necessity) for a follow-up study, or as the outcome of a study (either screening or ordered due to a sign or symptom without a specific diagnosis). These codes should not be used when a more specific diagnosis is known, but are useful when a test returns an abnormal result without confirmatory clinical findings. For example: e A 50-year-old man has a screening prostate specific antigen (PSA) as part of his annual exam. The results are elevated but the patient has no clinical indications of prostate cancer; report R97.20. ¢ A 68-year-old woman, status post-hysterectomy for prolapse, has a vaginal Pap smear as part of her annual breast and pelvic exam. Results show low grade squamous intraepithelial lesion (LGSIL) on cytologic smear of vagina; report R87.622. To code a nonspecific abnormal finding, start with the ICD-10-CM Alphabetic Index under the main term Findings. Abnormal, inconclusive, without diagnosis, are under the main term Abnormal (some codes are found under other main terms). . B | Elevated PSA. Look in the ICD-10-CM Alphabetic Index for Elevated, elevation/prostate specific antigen [PSA] R97.20. R97.20 Elevated prostate specific antigen Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (Z Codes) Z codes describe the reason for a test or study or the outcome of a study when results are negative or normal. * Exposure to communicable diseases—Use the codes in category 720 if the individual has been exposed to a communicable disease but has no signs or symptoms of infection. o Carrier—Use codes in category 722 for patients who are carriers or suspected carriers of a communicable disease but have no signs or symptoms of disease themselves. » Drug-resistant organisms—Category 716 is for use when a patient is known to have a specific disease resistant to typical drugs used to treat it. These codes are used for additional codes to identify resistance and non-responsiveness to drugs. You are instructed to code first the infection. There are also codes that include the infection and the organism. It is important to verify in the Tabular List. » Personal history—Categories 7Z85-787 list codes for individuals who have a personal history of various diseases requiring ongoing monitoring or therapy after the disease has been eradicated. These codes may be used only after there is no further indication of the disease, and after all active treatment directed toward the specific disease has ended. 3

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Chapter 18: Pathology and Laboratory Personal history of breast cancer. Look in the ICD-10-CM Alphabetic Index for History/personal (of )/malignant neoplasm (of)/breast Z85.3. 785.3 Personal history of malignant neoplasm of breast Allergy to medication—Category 788 describes patients with previous allergies to specific medications. Do not use these codes for a current allergy. These codes are fora personal history of drug allergy without a current reaction. Other history—There are other personal history codes, most of which do not apply to laboratory and pathology services, but a few can be useful, including subcategory 791.1 Patient’s noncompliance with medical treatment and regimen, which is specific to the reason for non-compliance and category 792 Personal history of medical treatment. Family history—Some tests are performed because a patient has family members with disorders. Categories Z80-784 describe these conditions; use only when the patient does not have a current diagnosis of the disease. Reproduction and development—Categories Z30-739 describe various encounters related to reproduction and contraception, including category Z36 Encounter for antenatal screening of mother. Do not use these codes when the patient has a current active illness or disorder. Organ or tissue replacement—Categories 794 report times when a patient has had a transplant. These are not codes to be used in the primary position. The first code should describe any disease, symptom, or other reason for the encounter. Procedures for aftercare—Categories Z47-7Z48 include many codes describing a follow-up visit or procedure. Some codes useful for pathology and laboratory services include category Z51 Encounter for other aftercare and medical care and category Z79 Long term (current) drug therapy. The long-term drug therapy codes supply the medical necessity for many follow-up lab tests. These codes are not used as the primary diagnosis but should be listed as a secondary code with the primary code listed as the condition or disease requiring drug use. Donor—Category Z52 is for examination of donors of organs and tissues. Any tests or studies performed to identify an individual as a donor should be reported with one of these codes. Pregnancy testing—UJse subcategory Z32.0 for pregnancy examination or test. The 5™ character identifies the result of the test. Screening—Tests are considered screening tests when there are no specific indications of disease or disorder. There are several codes representing various screening tests. They generally are found in categories Z11-Z13. Abbreviations and Acronyms BAC Blood alcohol content (or concentration) Hgb or Hb Hemoglobin Cr Creatinine MRSA Methiallin-resistant Staphylococcus Aureus CSF Cerebrospinal fluid PSA Prostate specific antigen Hct Hematocnt UA Urine analysis Section Review 18.2 1. 2. A patient has been exposed to rabies. He has no signs or symptoms of infection. A test is performed to check for rabies in his blood. What code describes the necessity for the test? A. 723 B. B97.89 C. 7203 D. As29 Answer: C. 7203 Rationale: The codes in category 720 are for exposure/contact to a disease without signs or symptoms of infection. Look in the ICD-10-CM Alphabetic Index for Exposure (to)/rabies 720.3. A woman has identified a lump in her right breast. After examination, the physician decides a biopsy is indicated. A specimen is sent for pathologic examination. The finding is carcinoma of the breast in the upper inner quadrant. What diagnosis is assigned for the pathologic examination? A. N63.12 B. Cso.1 C. (Cs50.211 D. 701.419 Hide Answer » Answer: C. C50.211 Rationale: Always code the most specific diagnosis known. When a diagnosis of carcinoma of the breast has been confirmed, it is inappropriate to code a less specific diagnosis, no matter the reason for the original test. In the ICD-10-CM Alphabetic Index, look for Carcinoma (malignant) (see also Neoplasm, by site, malignant). Go to the Table of Neoplasms, and look for Neoplasm, neoplastic/breast/upper inner quadrant/Malignant Primary (column) C50.2-. Verification in the Tabular List indicates that six characters are needed to complete the code. Report C50.211 for the upper inner quadrant of the right breast. 4

Chapter 18: Pathology and Laboratory 3. A patient with rheumatoid arthritis takes nonsteroidal anti-inflammatory drugs (NSAIDs) to manage pain. He also has regular blood tests to monitor kidney function due to his long-term use of the NSAIDs. What diagnosis coding describes the need for the test when the results are normal (the patient has no symptoms of liver disease)? A. Z79.1,751.81 B. Mo06.9,775.1,751.81 C. Mo6.9 D. Z79.1,M06.9 Hide Answer » Answer: B. M06.9, 779.1, 751.81 Rationale: Code both arthritis and the long-term use of NSAIDs. Look in the ICD-10-CM Alphabetic Index for Arthritis/rheumatoid, directing you to M06.9. For the next code, look for Therapy/drug, long term (current) (prophylactic)/anti-inflammatory directing you to Z79.1. There is an instructional note under category code Z79 to report also any therapeutic drug level monitoring with code Z51.81. This is found in the Alphabetic Index by looking for Monitoring (encounter for)/therapeutic drug level 751.81. Verify these codes in the Tabular List and read any instructions provided. 4. A patient has a history of prostate cancer with removal of the prostate and has completed radiation therapy with no recurrence for two years. A PSA is performed to check for any recurrence. The results show a PSA within normal limits. What diagnosis code(s) describe(s) this test? A. (61 B. Z08,785.46,790.79 €. 25 D. Z00.00 Answer: B. 708, 785 .46, 790.79 Rationale: Per ICD-10-CM coding guideline 1.C.21.c.8 follow-up codes are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. They imply that the condition has been fully treated and no longer exists. The follow-up code is sequenced first followed by the history code. Look in the ICD-10-CM Alphabetic Index for Examination/follow-up (routine) (following)/radiotherapy NEC/malignant neoplasm directing you to Z08. Once cancer has been excised and there is no further treatment directed toward the cancer site without recurrence, choose a personal history of malignancy code. Look for History/personal (of )/malignant neoplasm (of )/prostate directing you to Z85.46. Confirm codes in the Tabular List. According to AHA Coding Clinic (2000 Vol. 17 No.4) screening codes are not used for patients who have any sign or symptom of a suspected condition or history of a condition. The instructional note in the Tabular List for Z08 indicates to use additional code to identify any acquired absence of organs (Z90.-). Look in the Alphabetic Index for Absence/prostate (acquired), referring you to 790.79. 5. B C. D A woman comes in for her annual exam with a cervical Pap smear. The results are abnormal, although they are not diagnostic of any specific disease. A second Pap smear is obtained, and this test identifies only normal cells. What diagnosis code identifies the medical necessity for the second Pap smear? A. N92.6 N92.3 N92.4 R87.619 Answer: D. R87.619 Rationale: Choose a code that identifies unspecified previous abnormal findings on cervical Pap smear. Although the second test results came back normal, the previous abnormal finding supports the need for a repeat test. Look in the ICD-10-CM Alphabetic Index for Findings, abnormal, inconclusive, without diagnosis/Papanicolaou cervix, directing you to R87.619. Verify this code in the Tabular List. CPT® Coding Codes in the Pathology and Laboratory section of CPT* represent a wide diversity of codes and describe the work of performing a test, usually on some body fluid or tissue. These services are performed by a physician or by technologists under supervision of a physician. Some of the tests are simple and can be performed readily in a physician’s office. Some are complex and require special equipment and/or processes in addition to expert handling and interpretation. Some of these services produce only a test result returned to the ordering provider. For other services, there is an expectation an expert will interpret test results further to provide more information or a final diagnosis based on a combination of clinical information and examination of the specimen. For each subsection within this chapter, there are specific rules and limitations, which are discussed below. Organ or Disease-oriented Panels (80047-80081) Codes in this section describe panels of tests often ordered together. These codes are used whenever all the specific tests listed under the panel heading are performed, whether the panel is described with the same title or not. If one or more of the tests listed is not performed, the panel code may not be used, and the specific tests must be coded separately. If more tests than those listed in the panel are performed, the panel is coded, and additional tests are listed separately. The codes for each individual test are listed beside the test under each heading. According to AMA guidelines, “These panels were developed for coding purposes only and should not be interpreted as clinical parameters.” This guideline does not limit a laboratory from creating its own panels of tests and then assigning the appropriate codes. Also, these panels do not limit the physician from ordering other tests as medically necessary.

Chapter 18: Pathology and Laboratory Most of the panels are self-explanatory, but some specific rules should be noted. Several of the panels require all the tests in another panel be performed in addition to several other tests (for example, General Health Panel [80050] includes a Comprehensive Metabolic Panel [80053] as well as a blood count and thyroid stimulating hormone). To bill for the more extensive panel, every test listed in the less comprehensive panel must be performed in addition to any added tests listed in the more comprehensive panel. Several panels allow either of two different tests to be performed. These two tests produce the same information but can be performed in different ways. Obstetric Panel (80055) includes “Blood count, complete (CBC), automated and automated differential WBC count” OR “Blood count, complete (CBC), automated and appropriate manual differential WBC count.” Either test fulfills the requirements to bill the panel. Codes 80055 and 80081 are both used for obstetrical panels, with the difference being the addition of HIV testing on 80081. It is inappropriate to order 80055 and 87389 separately. The acute hepatitis panel is used for differential diagnosis in a patient with symptoms of liver disease or injury. When the time of exposure or the stage of the disease is not known, a patient with continued symptoms of liver disease—despite a completely negative hepatitis panel—may need a repeat panel approximately two weeks to two months later to exclude the possibility of hepatitis. Once a diagnosis is established, specific tests can be used to monitor the course of the disease. Therapeutic Drug Assays (80143-80299) Some drugs must be maintained at a therapeutic level to work effectively. Many of these same drugs can have negative side effects or even become toxic if levels get too high. These drugs require regular monitoring to confirm the level of the drug in the patient’s system. Many of these drugs are listed in the section called Therapeutic Drug Assays. Therapeutic drug assays are quantitative; and although the tissue most often examined is blood, these codes may be used for assays on serum, plasma, or cerebrospinal fluid. The concept of peak and trough is used during therapeutic drug assays. For the physician to properly adjust medication dosages, specimens (usually blood) are collected at a given time after a dose has been administered (the peak). The exact time is dependent upon the drug, the administration interval, and the amount of time it takes the drug to be absorbed by the body. The trough (or low-point) specimen is collected immediately before the next dose of the drug. Repeated tests during a drug assay are legitimate and should be coded. A number of drugs requiring monitoring for therapeutic levels are listed with specific codes in this section. Other drugs may be found in the Chemistry section as well. If there is no code for the drug being tested in either the Therapeutic Drug Assay section or the Chemistry section, use code 80299 Quantitation of therapeutic drug, not elsewhere specified to describe the service. Drug Screening (80305-80377) Drug screening is reported with codes in the 80305 to 80377 range. CPT* codes 80305-80307 report drug screening based on the method for testing the specimen; for example, direct optical observation or by instrument chemistry analyzers. Codes 80320-80377 report definitive drug testing of specific types of drugs — such as alcohol, amphetamines, and anabolic steroids, as well as drugs or substances that are not otherwise specified. Use the Definitive Drug Classes Listing to identify drugs and metabolites included in each definitive drug class. Evocative/Suppression Testing (80400-80439) Evocative/Suppression Testing describes how well various endocrine glands are functioning. Each code in the Evocative/Suppression Testing subsection includes several tests. The tests are performed after administration of an evocative or suppressive agent specific to the gland being tested. The administration of the agent is coded separately, as determined by the route of administration. The evocative or suppressive agent is intended either to cause the gland to secrete its hormone or cause the gland to cease production of the hormone. The tests measure the initial levels and subsequent levels of the hormone. Based on the test results, physicians can determine if it is lack of the agent or failure of the gland to respond to the agent causing a glandular dysfunction. Each of the tests listed in the panel code must be performed the number of times listed in the code. For example, code 80430 Growth hormone suppression panel (glucose administration) requires glucose to be measured three times and human growth hormone to be measured four times. Code extra tests separately. If fewer than the listed number of tests in the panel are performed, code each test separately. When physician attendance is not required and ancillary staff administers the agent, do not report these codes separately. In the inpatient setting, these codes are only reported if the physician performs the service personally. In the office setting, the service can be reported when performed by office personnel if the physician is directly supervising the service. While supplies necessary to perform testing are included in the testing, the HCPCS Level Il ] codes for the drugs can be reported separately for the diagnostic agents. Do not report evaluation and management (E/M) services separately, including prolonged services (in the case of prolonged infusions), unless a significant service can be identified separately and is provided and documented. If separate E/M services are provided and reported, the injection procedure is included in this service and is not reported separately. Clinical Pathology Consultations (80503-80506) Pathology consultation codes are reported when tissue samples are sent from another lab or pathologist for a second opinion on the diagnosis or other information. The code selection is determined by the complexity of the clinical problem, the amount of the patient’s medical record that is reviewed, and the level of medical decision making. The level of visit, the MDM is selected based on three components: 1. 'The number and complexity of problems addressed (includes pathology findings); 2. 'The amount and complexity of data to be reviewed and analyzed; and 3. The risk of complications and morbidity or mortality of patient management. The components of MDM are discussed further in chapter 19. Code selection may also be based on the total time spent on the date of the consultation. The activities included in consultant time are listed in the CPT* guidelines. Prolonged services for pathology consultations is reported with add-on code +80506. If time is a determining factor, the amount of time spent for the consultation must be clearly documented. Documentation of clinical pathology consultations requires a written report and request from the attending physician. Reporting of a test result without medical interpretive judgment is not considered a clinical pathology consultation.

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Chapter 18: Pathology and Laboratory Specific criteria must be met for these codes to be used: 1. The consultation must be requested; the pathologist should not provide the service automatically. 2. The service must require the interpretive judgment of the pathologist. For example, if the clinical chemist routinely evaluates and reports abnormal results, a pathologist’s consultation service has not been rendered. 3. A written report of findings must be prepared by the pathologist, forwarded to the surgeon or other provider, and included in the patient’s records. 4. The tests reviewed must be outside the clinically significant normal range, based on the patient’s condition. Urinalysis (81000-81099) Urinalysis includes both simple and complex tests and analyses. All tests are performed on urine specimens. Some of the tests most commonly performed in physician offices are in this section. Code 81000 describes a simple dipstick test checking for common changes in urine indicating disease. Similar, but more involved tests are coded with 81001-81003, requiring either special equipment or evaluation under the microscope. Codes 81005-81020 report complex analyses measuring quantities of these changes or screening for other conditions. Urine pregnancy test by color comparison (81025) is similar to tests commercially available over the counter. Volume measurement for timed collection (8 1050) measures the amount of urine produced over a period, usually 24 hours (often called a 24-hour urine). Molecular Pathology (81105-81408, 81479) The lab tests in the Molecular Pathology subsection examine nucleic acid to determine changes in genes that may indicate a germline (for example, an inherited constitutional chromosome abnormality), somatic condition (for example, neoplasm), or testing for histocompatibility antigens (for example, human leukocyte antigen (HLA). These lab tests represent a developing area of medical testing in finding clues to illnesses, their likelihood, and possible future treatments. Report these codes by how the test is performed to determine the result, not on the analyte (gene-to-gene variant). The code description for these lab codes breaks down this way: Code 81220 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; common variants (eg, ACMG/ACOG guidelines) * (ene abbreviation (CFTR) and gene name (cystic fibrosis transmembrane conductance regulator) » Example of disease being tested (cystic fibrosis) e Gene analysis o For what are we testing? (common variants) * [xample of variants being tested (American College of Medical Genetics and Genomics (ACMG) and American Congress of Obstetricians and Gynecologist (ACOG) guidelines). The Molecular Pathology guidelines instruct that when procedures, such as microdissection (codes 88380 and 88381), are performed prior to cell lysis, codes are reported separately. Report Tier 2 codes when procedures are not listed in the Tier 1 pathology codes. The Tier 2 codes are generally performed less often than the Tier 1 codes. These codes are very specific and listed by levels (Level 1-Level 9). Append modifier 26 to these codes when the physician provides an interpretation and report (professional component) for these laboratory procedures. Multianalyte Assays with Algorithmic Analyses (MAAAs) (81490-81599) MAAAs are algorithmic analyses using the results of assays (molecular pathology assays, fluorescent in situ hybridization assays and non-nucleic acid-based assays) and patient information when appropriate to report a numeric score(s) or probability of developing specific conditions. Chemistry (82009-84999) Tests in the Chemistry subsection detect many substances in the body, including naturally occurring, therapeutic or non-therapeutic drugs, and other substances. All codes describe quantitative analyses, unless otherwise specified. If a quantitative test for a therapeutic drug is performed and not listed here, it may be found in the Therapeutic Drug Assays subsection. Most of the tests are listed in alphabetic order, but some tests are at the end of the section in a more random order. The CPT* Index can be helpful in locating the correct code if you know the name of the test. Also included in this section are the molecular diagnostic codes, also known as nucleic acid or genetic tests. These codes describe the various steps in preparing a specimen for genetic analysis. The tests in this section may be performed on any body part, fluid, or tissue. If the same test is performed on more than one type of specimen, report each separately. Codes in this section describe tests for specific substances by any method. Albumin Serum Testing (82040-82045) Albumin testing is used in a variety of settings to help diagnose disease, to monitor changes in health status with treatment or with disease progression, and as a screen serving as an indicator for other kinds of testing. Low albumin levels can reflect kidney diseases, liver diseases, or prolonged malnutrition. Burn patients and patients who have protein-losing enteropathies and uropathies have low levels of protein, despite normal synthesis and require supplemental protein in many cases. Code 82045 reports albumin testing for cardiovascular events preceded by ischemia. Fecal Occult Blood (82270-82274) Different types of fecal hemoglobin assays exist, each directed at a different component of the hemoglobin molecule. 1. Immunoassays recognize antigenic sites on the globulin portion and are least affected by diet or proximal gut bleeding, but the antigen may be destroyed by fecal flora. 2. 'The heme porphyrin assay measures heme derived porphyrin and is least influenced by enterocolic metabolism or fecal storage. The capacity to detect proximal gut bleeding reduces its specificity for colorectal cancer screening but makes it more useful for evaluating overall gastrointestinal (GI) bleeding when finding iron deficiency anemia. 3. The guaiac-based test (82270-82272) is the most sensitive test for detecting lower bowel bleeding. 7

Chapter 18: Pathology and Laboratory Report code 82270 once for the testing of up to three separate specimens (comprising either one test or two tests per specimen). The patient may be given three cards or a single triplet card for consecutive collection. Do not report the test until the cards have been returned and the test performed. Code 82656 and 82653 report a noninvasive stool test to determine exocrine pancreatic function. Blood Glucose (82947, 82948, and 82962) Blood glucose values are often necessary for the management of patients with diabetes mellitus where hyperglycemia and hypoglycemia are often present. They are also critical in the determination of control of blood glucose levels in the patient with impaired fasting glucose (FPG 110-125 mg/dL), the patient with insulin resistance syndrome and carbohydrate intolerance (excessive rise in glucose following ingestion of glucose or glucose sources of food), in the patient with a hypoglycemia disorder such as nesidioblastosis or insulinoma, and in patients with a catabolic or malnutrition state. In addition to those conditions, glucose testing may be medically necessary in patients with tuberculosis, unexplained chronic or recurrent infections, alcoholism, coronary artery disease (especially women) or unexplained skin conditions (including pruritus, local skin infections, ulceration, and gangrene without an established cause). Many medical conditions may be a consequence of a sustained elevated or depressed serum glucose level. These include coma, seizures or epilepsy, confusion, abnormal hunger, abnormal weight loss or gain, and loss of sensation. Evaluation of glucose may also be indicated in patients on medications known to affect carbohydrate metabolism. Glycated Protein and Hemoglobin (82985, 83036) Glycated protein and hemoglobin levels are used to assess long-term (3 to 4 months) glucose control in diabetes. Alternative names for these tests include glycated or glycosylated hemoglobin or Hgb, hemoglobin glycated or glycosylated protein and fructosamine. Glycated hemoglobin (equivalent to hemoglobin A1, HbA 1 ¢ or similar abbreviations) refers to total glycosylated hemoglobin present in erythrocytes, usually determined by affinity or ion exchange chromatographic methodology. Helicobacter Pylori Testing (83009, 83013 and 83014) A Helicobacter pylori (H. pylori) bacterial infection contributes to the development of diseases, such as dyspepsia, gastritis, and ulcers in the stomach and duodenum. These bacteria have long threads that protrude and attach to the underlying stomach cells. The mucous layer protecting the stomach cells from acid also protects H. pylori, which can multiply and cause infection. Several methods are available for diagnosis. In the breath test, urea is contained in a capsule or liquid and given by mouth to indicate the presence of bacteria in the breakdown of urea into carbon dioxide. A blood test can measure protein antibodies present in the blood in defense of H. pylori. This antibody indicates whether the infection is present or was present but no longer in the system. Codes 83013 and 83014 report H. pylori breath test analysis for urease activity, and code 83009 reports a blood test analysis. Lactoferrin Measure (83630 and 83631) A test to measure lactoferrin in the feces can determine the presence of intestinal inflammation, differentiate inflammatory from non-inflammatory gastrointestinal disease, monitor patient response to therapy and predict inflammatory bowel disease recurrence. One code is available for qualitative determination while the other is available for quantitative determination. Lipoprotein (83695, 83700—-83704, 83718—83721) Code 83695 reports direct quantitative measurement of lipoprotein a [Lp(a)] in serum, which is an indicator for increased risk for myocardial infarction, stroke, coronary artery disease, vein graft stenosis, and retinal arterial occlusions when present in elevated blood concentrations. The test can be run using enzyme-linked immunosorbent assay (ELISA) and immunoturbidometric platforms with monoclonal antibodies against unique apo(a) epitopes used in the determination for Lp(a) being performed on a venipuncture serum sample. Codes 83700 and 83701 describe a group analysis of lipoproteins by methodology. Code 83700 describes electrophoretic separation and quantitation, and 83701 describes high- resolution fractionation and quantitation of lipoproteins including subclasses when performed. Code 83704 reports nuclear magnetic spectroscopy, which is a quantification method useful in assessing and managing cardiovascular disease among patients with elevated triglyceride levels and abnormalities associated with insulin resistance and diabetes. Cholesterol Measures (83721) Code 83721 Lipoprotein, direct measurement; (LDL) cholesterol reports the direct measurement of the LDL cholesterol. It should not be used to report calculated LDL cholesterol. Direct measurement of LDL cholesterol in addition to total cholesterol (code 82465) or lipid panel (code 80061) may be reasonable and necessary if the triglyceride level is too high to permit calculation of the LDL cholesterol. In such situations, report code 83721 with modifier 59. Prostate Specific Antigen (PSA) (84152-84154) PSA is used in differentiating benign from malignant disease in men with lower urinary tract signs and symptoms (for example, hematuria, slow urine stream, hesitancy, urgency, frequency, nocturia, or incontinence). It is also useful in patients with palpably abnormal prostate glands on physical exam and in patients with other laboratory or imaging studies suggestive of the possibility of a malignant prostate disorder. PSA is also a marker used to follow the progress of prostate cancer once a diagnosis has been established, such asin detecting metastatic or persistent disease in patients who may require additional treatment. PSA testing may also be useful in the differential diagnosis of men presenting with undiagnosed disseminated metastatic disease. Code R97.20 reports elevated PSA. If a more specific diagnosis has been made, assign the code for that diagnosis. Pregnancy-associated Plasma Protein-A (PAPP-A) (84163) Code 84163 describes a screening test to identify women at increased risk of carrying a fetus with a chromosomal abnormality, such as trisomy-18 or trisomy-21. A positive result does not mean the pregnancy is affected but it does indicate further testing is necessary, such as, chorionic villus sampling or amniocentesis. Electrophoresis (84165, 84166) Electrophoresis is a method of separating nucleic acids or proteins based on size, electric charge, and other physical properties. Code 84165 describes specific analysis of serum. For example, lipoprotein electrophoresis is a type of protein electrophoresis focused on determining the amount of lipoprotein (such as cholesterol). Code 84166 reports a protein electrophoresis for fluids other than serum, such as urine or cerebral spinal fluid (CSF) with concentration. Thyroid Testing (84436-84439, 84443, 84479) Thyroid function studies identify the presence or absence of hormonal abnormalities of the thyroid and pituitary glands. These abnormalities may be either primary or secondary and often accompany clinically defined signs and symptoms indicative of thyroid dysfunction. Measurements of serum sensitive thyroid-stimulating hormone (TSH) levels, complemented by determination of thyroid hormone levels [free thyroxine (fT-4) or total thyroxine (T4) with triiodothyronine (T3) uptake] are used for diagnosis and follow-up of patients with thyroid disorders. Additional tests may be necessary to evaluate certain complex diagnostic problems or in hospitalized patients where many circumstances can skew tests results.

Chapter 18: Pathology and Laboratory When a test for total thyroxine (total T4 or T4 radioimmunoassay) or T3 uptake is performed, calculation of the Free thyroxine index (FT1) can be useful to correct for abnormal results for either total T4 or T3 uptake due to protein binding effects. Code M62.81 reports muscle weakness as the indication for the test. Subcategory code E31.2- reports multiple endocrine neoplasia syndromes (MEN-1 and MEN-2). A 5™ character is reported based on the type of MEN; type |, type 1A, or type I1b. Hematology and Coagulation (85002-85999) Blood counts are used to evaluate and diagnose diseases relating to abnormalities of the blood or bone marrow. These include primary disorders such as anemia, leukemia, polycythemia, thrombocytosis, and thrombocytopenia. Many other conditions secondarily affect the blood or bone marrow, including reaction to inflammation and infections, coagulopathies, neoplasms, and exposure to toxic substances. Many treatments and therapies affect the blood or bone marrow, and blood counts may be used to monitor treatment progress. A complete blood count (CBC) includes a hemogram and differential white blood count (WBC). The hemogram includes enumeration of red blood cells, white blood cells, and platelets, as well as the determination of hemoglobin, hematocrit, and indices. Symptoms of hematological disorders are often nonspecific and are commonly encountered in patients who may prove to have a disorder of the blood or bone marrow. Many medical conditions may have hematological manifestations resulting from the disease or its treatment. As a result, the CBC is one of the most commonly indicated and ordered laboratory tests. If additional related procedures are necessary to confirm the result after a test is ordered and performed, these additional tests are considered part of the ordered test and not reported separately. R 1. If a patient with leukemia has thrombocytopenia, and a manual platelet count (code 85032) is performed in addition to the performance of an automated hemogram with automated platelet count (code 85025), it is inappropriate to report codes 85032 and 85025 because the former provides a confirmatory test for the automated hemogram and platelet count (code 85025). 2. Ifapatient has an abnormal test result and repeat performance of the test is done to verify the result, report the test as one unit of service rather than two. Bone Marrow Aspiration When a diagnostic bone marrow aspiration is performed alone, report surgical code 38220. Appropriate coding for the interpretation is code 85097 when the only service provided is the interpretation of the bone marrow smear. When the provider performs both procedures, report both CPT® codes. Do not report the pathological interpretations (codes 88300 to 88309) in addition to code 85097 unless separate specimens are processed. Prothrombin Time (85610) Basic plasma coagulation function is readily assessed with a few simple laboratory tests: the partial thromboplastin time (PTT), prothrombin time (PT), thrombin time (TT) ora quantitative fibrinogen determination. The PT test is one in vitro laboratory test used to assess coagulation. The PT or intermational normalized ratio (INR) is most commonly used to measure the effect of warfarin and regulate dosing of the medication. Warfarin blocks the effect of vitamin K on hepatic production of extrinsic coagulation pathway factors. PT is expressed in seconds or as an INR. The INR is the PT ratio resulting in the World Health Organization (WHO) reference that thromboplastin is used when performing the test. Immunology (86000-86849) Immunology is the study of the immune system. Codes in this subsection identify and quantify antigens, antibodies, and allergens. Antigens may be viruses, bacteria, or other immune triggers our body fights off by creating antibodies. Antibodies are elements the human body creates to deal with antigens, although sometimes antibodies are created in response to inflammatory changes or other stimuli in the body. Allergens are substances causing a histamine response in the body. Identifying and quantifying these elements can tell a physician which disease a patient has, whether someone has been exposed to a disease or has an active immunity, or has other immune issues to be treated. Most codes in this section are qualitative or semi-quantitative and describe multistep processes. Each substance should be coded as precisely as possible. If there is no code to describe the level of precision identified (for example, the specific class), report a more generic code multiple times to describe each separate substance tested. Tumor Antigen Immunoassay (86300-86304) Immunoassay determinations of serum levels of certain proteins or carbohydrates serve as tumor markers. When elevated, serum concentration of these markers may reflect tumor size and grade. A CA 125 (86304) level may be obtained as part of the initial preoperative workup for women presenting with a suspicious pelvic mass to be used as a baseline for purposes of postoperative monitoring and treatment. CA 125 is a high molecular weight serum tumor marker elevated in 80 percent of patients who present with epithelial ovarian carcinoma. It is also elevated in carcinomas of the fallopian tube, endometrium, endocervix, and many other benign conditions. An elevated level may also be associated with the presence of a malignant mesothelioma. Tumor antigen CA 19-9 (86301) is used in following the course of patients with established diagnosis of pancreatic and biliary ductal carcinoma. CA 15-3 (86300) is often medically necessary to aid in the management of patients with breast cancer. Serial testing is used in conjunction with other clinical methods for monitoring breast cancer. For monitoring, if medically necessary, use either CA 15-3 or CA 27.29 (86300), not both. CA 27.29 is equivalent to CA 15-3 in its usage in management of patients with breast cancer. Hematology (86355, 86357, 86367) These codes describe procedures used in the evaluation of hematologic conditions. Code 86355 reports B cells; code 86357 reports natural killer (NK) cells; and code 86367 is used to report stem cells in the evaluation of hematologic conditions. All three codes report total count and are used for quantitative analysis. They do not include an interpretive report. B cells, which are produced in the bone marrow, secrete antibodies. Each B cell can make one specific antibody. NK cells are the most aggressive cells of the immune system. They are the first line of defense against mutant and virus infected cells like severe acute respiratory syndrome (SARS) or West Nile virus (WNV) and they destroy infected and cancerous cells. NK cells make up about 5 to 16 percent of the total lymphocyte population. Stem cells are primitive cells giving rise to other types of cells. Adult and embryonic stem cell research focuses on the etiology, progression, and treatment of disease. HIV Testing (86689, 86701-86703, 87390, 87391, 87534—-87539) Diagnosis of human immunodeficiency virus (HIV) infection is primarily made using serologic assays. These assays take one of two forms: antibody detection assays and specific HIV antigen procedures. The antibody assays are usually enzyme immunoassays (EIA), which are used to confirm exposure of an individual’'s immune system to specific viral antigens. These assays may be formatted to detect HIV-1, HIV-2, or HIV-1 and 2 simultaneously, and to detect both IgM and IgG antibodies. When the initial EIA test is repeatedly positive or indeterminate, an alternative test is used to confirm the specificity of the antibodies to individual viral components. The Western Blot test (86689) is performed after documenting that the initial EIA tests are repeatedly positive or equivocal on a single sample. 9

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Chapter 18: Pathology and Laboratory Testing for evidence of HIV infection using serologic methods may be medically appropriate in situations where there is a risk of exposure to HIV. However, in the absence of documented Acquired Immune Deficiency Syndrome (AIDS) defining or HIV associated disease, an HIV associated sign or symptom or documented exposure to a known HIV infected source, the testing is considered to be screening and may not be covered (for example, history of multiple blood component transfusions, exposure to blood or body fluids not resulting in consideration of therapy, history of transplant, history of illicit drug use, multiple sexual partners, same sex encounters, prostitution, or contact with prostitutes). The CPT® Editorial Panel has issued several codes for infectious agent detection by direct antigen or nucleic acid probe techniques not yet developed or are only being used on an investigational basis. Laboratory providers are advised to remain current on Federal Drug Administration (FDA) approval status for these tests. Blood Banking and Tissue Typing (86077-86079, 86805—-86849) Codes to describe blood banking (86077-86079) and tissue typing (86805-86821) services also are found in Immunology subsection. This may be confusing because you might expect to find the codes, particularly the blood banking codes, in the subsections on Hematology or Transfusion Medicine. These codes deal with procedures specific to immunologic reactions to foreign tissue in the human body. Blood banking services deal specifically with various transfusion reactions. Tissue typing studies consider the immunologic factors making a specimen appropriate for transplant or not a transplant candidate. Blood banking services do not need to take place in a blood bank. The codes describe specific services, not specific locations. They may be coded anytime the described services are performed. Transfusion Medicine (86850-86999) Blood is a raw material from which a range of therapeutic products including platelet concentrates, red cell concentrates (packed red blood cells (RBCs)) and fresh plasma is made. Large amounts of plasma are also needed to produce plasma derivatives, such as albumin, coagulation factors and immunoglobulin. The two most common reasons for a blood transfusion are: » Replace blood lost during an operation or after an accident e Treat anemia (lack of red blood cells) Small amounts of blood lost through surgery can be replaced by solutions of salt or glucose or using synthetic substances such as dextrin or gelatin. Larger amounts of lost blood or rapid blood loss may require blood transfusion. Anemia has a number of causes, but in all cases, there is an insufficient supply of red cells to carry oxygen. Medicines, vitamins, and blood transfusions are treatments for anemia. Following donation, each individual unit of blood is tested for viruses possibly transmitted by blood (for example, hepatitis B, hepatitis C, and HIV, the virus causing AIDS). Only blood testing negative is used for transfusion. Each donation is also tested to determine the ABO and Rh D blood group. A patient’s blood is tested prior to a transfusion for compatibility with the donated blood. ABO blood group is the major human blood group system and the type depends upon the presence or absence of two genes: the A and B genes. These genes are encoded on chromosome 9 (in band 9q34.1). They determine part of the configuration of the red blood cell surface. A person can be A, B, AB, or 0. If a person has two A genes, their red blood cells are type A. If a person has two B genes, their red cells are type B. If the person has one A and one B gene, their red cells are type AB. If the person has neither the A nor B gene, they are type 0. The situation with antibodies in blood plasma is just the opposite. Someone with type A red cells has anti-B antibodies (antibodies directed against type B red cells) in their blood plasma. Someone with type B red cells has anti-A antibodies in plasma. Someone who is type O has both anti-A and anti-B antibodies in plasma. And someone who is type AB has neither anti-A nor anti-B antibodies in their plasma. Antibody Screening (86850) Antibody screening for unexpected anti-RBC antibodies is routinely done on pre-transfusion specimens from prospective recipients and prenatally on maternal specimens. Unexpected antibodies are specific for RBC blood group antigens other than A and B, such as Rh(D), Kell(K), or Duffy{Fya). Early detection is important because such antibodies can cause hemolytic disease of the newborn (HDN), serious transfusion reactions, and may complicate testing and procurement of blood. Direct Coombs Test (86880) Direct antiglobulin testing detects antibodies coating the patient’s RBC in vivo. Washed RBCs have their own plasma removed before being directly tested with antihuman globulin and observed for agglutination or clotting. A positive test, if correlated with clinical findings, suggests autoimmune hemolytic anemia, a transfusion reaction, or HDN. Indirect Coombs Test (86885 and 86886) Indirect antiglobulin testing is screening for unexpected anti-RBC antibodies. Once an antibody is detected, its specificity is determined. Knowing the specificity of the antibody is helpful in assessing its clinical significance, selecting compatible blood, and managing HDN. ABO Typing (86900) ABO serologic typing of donor and recipient blood is done to prevent transfusion of incompatible RBC. As a rule, blood for transfusion should be of the same ABO type as the recipient. Individuals with type O blood do produce antigens. As a result, type O people are universal donors for transfusions, but they can receive only type O blood. Individuals with type AB blood can receive blood of any blood type but can only donate to those with AB blood. Rh Typing (86901) Rh (D) serologic typing determines whether the Rh factor, Rh (D), is present (Rh-positive), or absent (Rh-negative) on the RBC. Rh-negative patients should always receive Rh- negative blood, except in life-threatening emergencies when Rh-negative blood is unavailable. Rh-positive patients may receive Rh-positive or Rh-negative blood. Compatibility Test (86920-86923) Code 86920 provides an immediate spin cross-match and code 86922 uses an antiglobulin technique. Code 86923 reports the cross-match service when the laboratory information system verifies ABO compatibility of the unit of blood with the intended recipient. Microbiology (87003-87999) The Microbiology subsection includes: bacteriology (the identification and study of bacteria); mycology (the identification and study of fungi); parasitology (the identification and study of parasites); and virology (the identification and study of viruses). Identification is performed by one of two methods: presumptive or definitive. Presumptive identification is performed by identifying the characteristics of the microorganism. The tester looks at growth patterns, color, success in culturing the specimen in certain media, etc. Definitive identification requires other methods to identify the genus and species of the microorganism and may require deoxyribonucleic acid (DNA) analysis (code separately). 10

Chapter 18: Pathology and Laboratory Codes are specific to the source material for the study. Starting with code 87260, the source material must be primary only (the source is the individual’s blood or other tissue for direct examination). Secondary sources, including materials grown on media, are not reported with these codes. Code the infectious agent as specifically as possible. Testing of unidentified infectious agents or agents without a specific code may be reported by testing technique using 87300. This section also includes codes for the work of identifying drugs to which the organism may be susceptible or resistant. Although most of the codes in this section require special equipment and expertise, a few codes describe services performed routinely in a physician’s office. The most common is the rapid strep test, or RADT—a reagent strip test for group A Streptococcus commonly performed to test for strep throat. Rapid strep tests are CLIA waived tests reported with 87880. CPT* subsection guidelines for Microbiology instruct to report modifier 59 when the same lab test is performed on multiple specimens or sites. For example: For a chlamydia culture taken from the vaginal area and another culture taken using urine, report code 87110 twice, and append maodifier 59 to the second code (87110, 87110-59). Bacterial Urine Culture (87086—-87088, 87184, and 87186) A bacterial urine culture is a laboratory procedure performed on a urine specimen to establish the probable etiology of a presumed urinary tract infection. It is common practice to do a urinalysis prior to a urine culture. A urine culture may also be used as part of the evaluation and management (E/M) of another related condition. The procedure includes aerobic agar-based isolation of bacteria or other cultivable organisms present and quantification of the types present based on morphologic criteria. Isolates deemed significant may be subjected to additional identification and susceptibility procedures as requested by the ordering physician. The physician’s request must be clearly documented and communicated via laboratory protocols. Assign code 87086 one time per encounter. Colony count restrictions ordinarily do not apply to code 87088 because counts may vary greatly according to syndrome or other clinical circumstances (for example, antecedent therapy, collection time, degree of hydration). You may report codes 87088, 87184, and 87186 multiple times in association with, or independent of, code 87086 because urinary tract infections may be polymicrobial and the codes specify each isolate or each antimicrobial. Infectious Agent Detection by Nucleic Acid (DNA or RNA); HIV-1 or-2 (87536 and 87539) Human immunodeficiency virus (HIV) quantification is achieved using a number of different assays measuring the amount of circulating viral RNA. Assays vary both in methods used to detect viral RNA as well as in ability to detect viral levels at lower limits. However, all employ some type of nucleic acid amplification technique to enhance sensitivity, and results are expressed as the HIV copy number. HIV copy number is also referred to as viral load. It is an expression of the concentration of the HIV virus in the blood. Itis used as a guide to treatment decisions and to monitor response to treatment. Quantification assays of HIV plasma RNA are used to assess relative risk for disease progression and predict the time until death, as well as to assess efficacy of antiretroviral therapies. HIV quantification is often performed together with CD4+ T cell counts providing information on the extent of HIV induced immune system damage. Do not report CPT* codes for quantification simultaneously with other nucleic acid detection codes for HIV-1 (87534, 87535) or HIV-2 (87537, 87538). Human Papillomavirus Detection (87623-87625) Human papillomavirus (HPV) testing is done to detect whether certain types of HPV are present. HPV can cause an abnormal Pap smear result. There are many types of HPV. Some types cause common, plantar, filiform, or flat warts. Other types cause genital warts, a sexually transmitted disease affecting men and women. In women, high-risk types of HPV (such as types 16, 18, 31, and 45) cause changes in the cells of the cervix; they are seen as abnormal cells on a Pap smear. Abnormal cervical cells may resolve without treatment; however, some untreated cervical cell changes can lead to cervical dysplasia and cervical cancer. HPV testing detects the genetic material of human papillomavirus. Like a Pap smear, an HPV test is done on a sample of cells collected from the cervix. Immunoassay with Optical Observation (87802-87807) The procedures described in these codes assist physicians in making a rapid and accurate diagnosis of diseases such as influenza (87804) and respiratory syncytial virus (RSV) code (87807) through antigen detection followed by conventional viral culture and using a direct optical (i.e., visual) immunoassay. Common methods of collection for testing include nasopharyngeal swabs, bronchoalveolar lavage fluids, nasal washes and throat swabs. Anatomic Pathology (88000-88099) The Anatomic Pathology subsection includes all the postmortem pathologic examinations, or necropsies, more commonly called autopsies. Codes in this section vary based on whether the study is gross only, or gross and microscopic. There are further differentiations based on whether the central nervous system (brain and spinal cord) is included in the examination. CPT® 88040 describes forensic necropsy examination; 88045 reports a coroner’s call. Forensic examinations are detailed exams for legal evidence. A coroner’s call is for a response to a crime scene or accident. Cytopathology (88104-88199) Cytopathology is a branch of pathology studying diseases on the cellular or individual cell level. The most common cytopathologic study is the Pap smear, which is an examination of cervical or vaginal cells. Pap Smears (88141-88155, 8816488167, 88174—-88175) During a Pap smear, a small sample of cells from the surface of the cervix is collected and spread or smeared on a slide or the cervical samples are placed into a vial of liquid preservative and sent to a lab for examination under a microscope. The cells are examined for abnormalities indicating cancer or changes leading to cancer (pre-cancerous). Vagina Bladder i, s —~ Uterus Ry T Tt L Vertebra N\ £ L_\ | Rectum ~N \ Cytobrush inserted po Smeo rs into cervical os to Spatula scraping off ectocervical cbtain endocervical cells cells from outer surface of the cervix ~ J 11

Chapter 18: Pathology and Laboratory Cervical cancer has well-defined stages, and chances of a cure are much higher when it is detected before it has spread from the cervix to other parts of the body. All abnormal diagnostic Pap smears requiring an interpretation by the pathologist are assigned the additional pathologist code, 88141, regardless of screening (manual or computer) method or slide preparation method. Code 88141 is always combined with a technical service code. Three subsets of technical service codes report cervical and vaginal screening and physician interpretation services. Pap smear results are reported by two methods: Bethesda and non-Bethesda. The Bethesda system of reporting allows for uniform reporting of results. Under the Bethesda system, Pap smear samples having no cell abnormalities are reported as “negative for intraepithelial lesion or malignancy” Samples with cell abnormalities are divided into the following categories: o ASC—atypical squamous cells o ASC-US—atypical squamous cells of undetermined significance, pronounced “ask-us” for ASC-US » ASC-H—atypical squamous cells cannot exclude a high-grade squamous intraepithelial lesion * AGC—artypical glandular cells ¢ AlS—endocervical adenocarcinoma in sitw, Ca in situ or CIS (carcinoma in situ) e [SIL—low-grade squamous intraepithelial lesion » HSIL—high-grade squamous intraepithelial lesion Similar studies can also be performed on aspirated fluids or cells obtained by washing or brushings. Pap Tests Manual Manual screening | Manual screening and Manual screening and computer ' Automated screening plus rescreening computer assisted assisted rescreening using cell computer rescreening selection screening Conventional spray-fixed smear, Bethesda reporting | 88164 88165 88166 88167 88147 system Conventional spray-fixed smear, non-Bethesda 88150 88153 88152 88147 reporting system Liquid-based specimen preparation any systemof | 88142 88143 88147 reporting, by any vendor’s instrument Pathologist diagnostic interpretation of an 88141 88141 88141 88141 88141 abnormal diagnostic smear, any type of preparation, any reporting system Flow Cytometry (88182-88189) Flow cytometry (88182-88189), or FCM, is a technique for counting and examining microscopic particles, such as cells and chromosomes, by suspending them in a stream of fluid and passing them by an electronic detection apparatus. It allows simultaneous multiparametric analysis of the physical and chemical characteristics of up to thousands of particles per second. Flow cytometry is used routinely in the diagnosis of health disorders, especially blood cancers, but has many applications. Cytogenetic Studies (88230-88299) Cytogenetics is a branch of genetics concerned with the study of the structure and function of the cell, especially chromosomes. [t includes routine analysis of G-banded chromosomes, other cytogenetic banding techniques, as well as molecular cytogenetics such as fluorescent in situ hybridization (FISH) and comparative genomic hybridization (CGH). Also in this subsection are codes for storage and thawing of materials for cytogenic analysis. Surgical Pathology (88300-88399) Basic surgical pathology services include accession, examination, and reporting. Documentation of all three components is required to bill for the service. One code, 88300, reports when only gross examination is needed. The other codes require both gross and microscopic examination. Successive codes represent increasing levels of physician work. The type of specimen, including how the specimen was obtained, determines the code selected. For example, a colon biopsy is assigned to Level IV (88305), a colon segmental resection fora condition other than a tumor is assigned to a Level V (88307), and a colon segmental resection for tumor is assigned to a Level VI (88309). This subsection also includes codes for special treatment of specimens including special stains and decalcification of specimens. Appendix (88302, 88304) Two surgical pathology codes are described for the appendix: 88302 represents Appendix, incidental, (the appendix is being removed during the same operative session of another procedure); 88304 represents Appendix, other than incidental (appendectomy is the only surgery being performed). Needle Core Biopsies (88305, 88307) Needle core biopsies are coded 88305 or 88307, depending on the source. If there is an immediate determination of adequacy of the core biopsy using a cytologic touch preparation, report 88333 for the intraoperative consultation of the initial site and 88334 for each additional site. Cervical Loop Electrical Excision (88305, 88307) The ectocervical portion of a cervical loop electrosurgical excision procedure (LEEP) is coded like a cervical conization (88307). If it is submitted as separate specimens, each procedure is coded as 88305 or 88307, depending on the work involved. Small endocervical samples are comparable to endocervical biopsy or endocervical curettage (ECC) and reported with 88305. A larger endocervical LEEP is comparable to a cervical conization and is reported with 88307. Lymph Nodes There are exceptions for coding separately for lymph node examinations. For example, do not report the examination separately: ¢ When the CPT* designation specifically includes lymph nodes (for example, 88309, mastectomy or laryngectomy with regional lymph nodes); or ¢ When lymph nodes are ordinarily attached to the specimen (for example, a lymph node adjacent to the neck of the gallbladder with a cholecystectomy [88304] or colectomy for neoplasm with mesenteric lymph nodes [88309]). 12

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Chapter 18: Pathology and Laboratory Certain circumstances warrant separate codes. For example, periaortic lymph nodes generally are not removed with the colon or gallbladder and, if submitted, are coded separately. When multiple regional lymph node resections are dissected, each is examined separately to establish the presence and extent of metastasis and each dissection is reported separately. A radical prostate resection does not include regional lymph nodes, and each regional lymph node dissection is reported separately in addition to 88309. A sentinel lymph node biopsy is not a component of a regional lymph node dissection, and the work in evaluating the sentinel lymph node is a distinct service. When a sentinel lymph node biopsy is accompanied by a lymph node dissection, separately code both services. Special Stains (88312-88314) Special Stains codes are assigned per stain, per specimen regardless of the number of slides stained. For example, for one specimen with one special stain on multiple slides, assign the appropriate Special Stains code only once; and for one specimen receiving three special stains, code separately each special stain. Consultations (88321, 88323, 88325) Consultations with reports on referred slides and material requiring preparation of slides prepared elsewhere refer to a single accession from another laboratory and can include multiple specimens. For example, a pathologist obtains prior mastectomy and colectomy specimens for comparison of different tumors with a fine needle aspiration (FNA) biopsy of a possible recurrence. Code each separately. Report slides from a radical hysterectomy with multiple specimens representing different lymph node groups or peritoneal samplings as a single consultation. CPT® 88325 reports the review of the patient’s chart, laboratory results, oncologist’s consultations, etc. It is not intended for use when review of the record is limited to pathology reports. Intraoperative Cytologic Exam (88329-88334) Intraoperative consultations (88329-88334) are services performed during operative sessions including frozen sections and touch preps (quick tissue examinations for abnormal cells requiring further excision). Code 88329 is reported when visual exam occurs without making any cuts into the specimen. Code 88331 describes the exam of the initial frozen section(s) (single specimen) and code 88332 reports each additional tissue block with frozen section(s). Two codes describe intraoperative cytologic exams (via touch or squash preparation) and consultation to provide immediate diagnosis during an intraoperative consultation without the involvement of frozen section. They are distinguished by the initial site (88333) and examination of each additional specimen (88334). Code 88334 reports each additional specimen in addition to the initial site exam (88333) and the frozen section evaluation (88331). Report 88334 once per encounter, when applicable. DNA Ploidy and S-phase Analysis (88358) Code 88358 reports DNA ploidy and S-phase analysis. One unit of service for code 88358 includes both DNA ploidy and S-phase analysis. DNA ploidy is a measurement of DNA content in tumor cells which is indicative of benign or malignant status. Quantitative Immunohistochemistry (88361) Quantitative immunohistochemistry by digital cellular imaging is reported with code 88361. Do not assign this code to any service other than quantitative immunocytochemistry by digital cellular imaging. Digital cellular imaging includes computer software analysis of stained microscopic slides. In Situ Hybridization (ISH) (88364-88377) ISH is used as a definitive marker for certain cancers. Codes 88367 and 88368 describe manual and computer assisted analyses for the first single probe stain. Fluorescent in situ hybridization (FISH) (code 88365) uses fluorescent dyes to identify each of the human chromosomes. This code also reports the first single probe stain. If additional stains are performed, assign the appropriate add-on code. Quantitative studies, as identified by code 88358 (morphometric analysis), performed as an adjunct to ISH procedures, are used increasingly to identify chromosomal abnormalities such as trisomy of chromosomes 18 and 21. Medicare does not pay for duplicate testing codes 88342 (immunohistochemistry or immunocytochemistry, per specimen) and codes 88184—-881889 (flow cytometry) should not be reported for the same or similar specimens. The diagnosis should be established using one of these methods. The provider may report both CPT® codes if both methods are required because the initial method is non-diagnostic or does not explain the light microscopic findings. The provider can report both methods utilizing modifier 59 and document the need for both methods in the medical record. If the abnormal cells in two or more specimens are morphologically similar and testing on one specimen by one method (88342 or 88184-88189) establishes the diagnosis, do not report the other method on the same or similar specimen. Similar specimens include: ¢ Blood and bone marrow ¢ Bone marrow aspiration and bone marrow biopsy * Two separate lymph nodes » Lymph node and other tissue with lymphoid infiltrate In Vivo Laboratory Procedures (88720-88749) CPT* code 88740 is performed to determine whether a patient has carbon monoxide poisoning. Code 88741 is used to determine if a patient suffers from methemoglobinemia. Methemoglobinemia is a blood disorder in which an abnormal amount of methemoglobin builds up in the blood. Other Procedures (89049-89240) This group of CPT® codes is a catchall for all other laboratory and pathology procedures not easily classified with other service codes. Some of the service codes describe collection of various body fluids routinely performed by lab personnel (for example, gastric intubation, nasal smears, sputum collection and sweat collection). Cell Count (89050) Miscellaneous body fluids (for example, cerebral spinal fluid [CSF], joint fluid) are listed when cells are counted in fluids other than blood. Patients presenting with suspected meningitis, for example, have CSF withdrawn and several tests run. One of these tests is microscopic examination. The presence of any cells, whether red blood cells, white blood cells, or microbes, is considered significant. 13

Chapter 18: Pathology and Laboratory Sputum Induction (89220) Sputum induction is a noninvasive procedure using an ultrasonic nebulizer to induce a sputum specimen for microbiological staining for diagnosis of a variety of organisms, including Mycobacterium tuberculosis and Pneumocystis carinii pneumonia (PCP). Sputum induction is an alternative to bronchoalveolar lavage to obtain a rapid diagnosis. Documentation in the medical record should include: ¢ Date and time of procedure ¢ Length of procedure ¢ Mode of therapy e Medication administered (if applicable) ¢ Patient tolerance s Pre- and post-heart rates e Pre- and post-breath sounds e Cough effort Sweat Test (89230) CPT* code 89230 reports the collection of sweat stimulated with an inducer by pilocarpine iontophoresis. An elevated level of chloride in sweat may indicate a laboratory diagnosis of cystic fibrosis. Reproductive Medicine Procedures (89250-89398) The subsection Reproductive Medicine Procedures houses codes for reporting reproductive medicine. Infertility may be due to problems in either the male or the female partner. Male problems may be contributory in 30 percent to 40 percent of infertile couples. The initial screening evaluation of the male partner includes a history and two semen analyses. Commonly called a “sperm count,” the number of live, motile sperm in a sample is estimated. Semen cultures check for bacteria causing genital infection. Biochemical analysis of semen measures various chemicals in semen such as fructose. Other tests include: 1. Sperm antibodies (89325) tests for antibodies binding to sperm and may reduce fertility. 2. Sperm penetration assay (Hamster egg penetration test, 89329) measures sperm-egg membrane fusion, using hamster eggs and the male’s sperm to test the capability of the sperm to penetrate the egg during In vitro fertilization (IVF). Code 89250 reports the culture of immature oocytes, but excludes the term “fertilization,” which may or may not be performed. Code 89272 reports separate techniques for additional culture from an eight-cell embryo (4-7 days) to blastocyst. Report insemination separately with CPT* codes 89280 and 89281. Code 89281 reports the additional work of microfertilization of greater than 10 oocytes in culture techniques involving tissue culture of human oocytes/embryos in the presence of oviductal, uterine, granulosa, or other substrate cells. Microscopic and cytochemical examination of the substrate cells may be used to determine their viability or functionality. Code 89268 reports the insemination of oocytes to achieve fertilization, which involves introduction of human spermatozoa isolated from seminal plasma into a culture dish containing oocytes. Semen analysis and sperm preparation must be performed prior to this procedure to assess sperm parameters necessary for fertilization. This procedure also includes microscopic examination of spermatozoa and oocytes to determine viability or functionality. Culture of human oocytes/embryos involves the identification, isolation, and incubation of these cells in culture medium and the maintenance of oocytes/embryo viability and functionality. Report laboratory services separately from physician services. Code 89272 reports the extended culture of human oocytes/embryos and includes the identification, isolation, and incubation of these cells in culture medium and includes maintenance of culture viability and functionality. This does not include the work of 89250. Proprietary Laboratory Analysis Proprietary Laboratory Analysis (PLA) are codes specific to lab tests or manufacturers that want to specifically identify their test. Because these tests are specific to a particular test or manufacturer, the coding for these labs is straightforward. This set of codes consists of four digits followed by the letter U (for example, 00220). HCPCS Level lI HCPCS Level Il codes beginning with P are specific for pathology and laboratory services (P2028-P9615). They are of limited use, as most pathology and laboratory services are coded from CPT®, ¢ lLaboratory Tests of Blood and Hair (P2028-P2038) e Pap Smears (P3000-P3001) ¢ Urine Bacterial Culture and Sensitivity Studies (P7001) ¢ Blood and Blood Products, with Associated Procedures (P9010-P9072) ¢ Specimen Collection, Travel Allowance (P9603-P9604) ¢ Specimen Collection, Catheterization (P9612, P9615) Modifiers CPT® modifier 26 indicates the professional component of the service only was performed, and HCPCS Level Il modifier TC indicates the technical component of the service only was performed. Most codes in the Pathology and Laboratory section have both a professional and a technical component. When the provider performs both professional and technical components, it is a global service, and modifiers are not used. The technical component of any test includes the work of preparing and running the test, as well as the equipment and supplies involved. It also includes the time and skill of the individual who performed the test. When a test is performed in a hospital or other facility setting, the reimbursement for the technical component of the service belongs to the facility. Likewise, when a test is performed in a physician’s office and sent out for interpretation, the test code is billed with modifier TC. The professional component is the interpretation of the results with a written report of the interpretation. When the physician writes an interpretive report based on outsourced test results, report the test code and append modifier 26. 14

Chapter 18: Pathology and Laboratory If the service is performed in a physician’s office and a report is written with the interpretation of the results, bill the test code without a modifier. Although other CPT* modifiers (notably 59, 76, and 77) are used in the appropriate circumstances as described in other chapters, three other modifiers apply specifically to the Pathology and Laboratory codes: * Modifier 90 reports when an office or facility bills for a test performed at an outside reference laboratory. This occurs when the reference lab bills the facility for testing and the facility or physician office bills the insurer for the test. There are many payer-specific rules about billing for a reference lab; you need to know the rules for each specific payer. Modifier 91 indicates a repeat diagnostic test was needed. It is like modifiers 76 and 77 but does not specify a provider. This is appropriate for tests not having a separate professional component. Medical necessity must be documented. A test repeated because of an error, or because the specimen was insufficient, is not a separately billable service. Modifier 91 is not used when multiple tests are indicated by code description. Modifier 92 describes testing using special single-use transportable equipment or kit. This equipment often is used when tests are performed in other patient locations, but the use of the modifier is not limited to other locations. It may be reported any time the equipment is used. Modifier 92 is added to the code describing the basic test performed. Modifier QW indicates a CLIA waived test. This modifier is required for Medicare claims. Other payers may require it as well as an indication that the service provider has a CLIA waived certificate. Clinical Laboratory Improvement Amendments (CLIA) The 1988 Clinical Laboratory Improvement Amendments (CLIA) require all laboratories examining materials derived from the human body for diagnosis, prevention, or treatment purposes to be certified by the U.S. Department of Health and Human Services (HHS). The Centers for Medicare & Medicaid Services (CMS) administers the CLIA laboratory certification program for the HHS secretary, in conjunction with the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). A description of the program is available online at: www.cms gov/clia/. All laboratory testing sites (for example, physician’s offices, hospitals, independent laboratories, ambulatory surgical centers, community clinics, ESRD facilities, health fairs, health maintenance organizations [HMO], home health agencies [[HHA], rural health clinics [RHC], pharmacies, industry, mobility units, student health centers, blood banks and tissue repositories) must be registered with CLIA. These sites must have either a registration certificate for moderate or complex testing or a CLIA certificate of waiver to legally perform lab tests in the United States. Claims will be denied for labs not meeting these stipulations and the provider may not bill the patient for the services provided. Violation of CLIA regulations is punishable by fines and imprisonment. Tests typically performed in the provider’s office are less complex and are classified as waived. The provider must have a certificate of waiver to perform these tests in office. Modifier QW usually needs to be appended to the HCPCS Level | or Level Il code for Medicare claims given the designation CLIA waived. Dipstick urinalysis non-automated and urine pregnancy tests do not require modifier QW. To determine whether the QW modifier is required, refer to the CLIA waived list provided by CMS. Modifier QW can be found in the HCPCS Level Il code book. A comprehensive list of these tests can be found at: www.cms.gov/Regulations-and-Guidance/Legislation/CLIA /Categorization_of Tests huml. CLIA waived tests are produced by a variety of pharmaceutical manufacturers. Section Review 18.3 A patient with deep vein thrombosis requires heparin to maintain therapeutic anticoagulation levels. He has regular PTTs drawn to monitor his level of anticoagulation. What code describes this testing? A. 85730 B. 85520 C. 80299 D. None of these Answer: A. 85730 Rationale: PTT stands for partial thromboplastin time. Look in the CPT® Index for PTT/Partial Thromboplastin Time (PTT) referring you to 85730-85732. Checking the listing, 85730 Thromboplastin time, partial (PTT); plasma or whole blood is the correct code for this test. 2. What s the code and any required modifier(s) for dipstick urinalysis, non-automated, without microscopy performed in a physician office for a Medicare patient? A. 81025-26-QW B. 81002-26-QW C. s81002-QW D. 81002 Hide Answer Answer: D. 81002 Rationale: 81002 is for dipstick urinalysis. Modifier 26 is not needed in the physician office. Code 81002 is a CLIA-waived test but is one of the codes that does not require modifier QW. Look in the CPT® Index for Urinalysis/Routine. 15

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3. Chapter 18: Pathology and Laboratory 4. A patient presents with right upper quadrant pain, nausea, and other symptoms of liver disease as well as complaints of decreased urination. Her physician orders an albumin; bilirubin, both total and direct; alkaline phosphatase; total protein; alanine amino transferase; aspartate amino transferase, and creatinine. How should this be coded? A. 82040, 82247 82248, 84075, 84155, 84460, 84450, 82565 B. 80076,82565 C. 80076 D. 80076-22 Answer: B. 80076, 82565 Rationale: Code the panel when all the tests listed in the panel are completed. If additional tests are also performed, they are coded separately. The first 7 tests are all listed in code 80076. This leaves creatinine, which is reported with code 82565. Look in the CPT® Index for Blood Tests/Panels/Hepatic Function and you are directed to 80076. Next, look for Creatinine/Blood directing you to 82565. Verify these codes. service? B C D. A 27-year-old male dies of a gunshot wound. An autopsy is performed to gain evidence for the police investigation and any subsequent trial. What code describes this A. 88005 88025 88040 88045 Answer: C. 88040 Read the code to verify this as the correct listing. Rationale: Services related to legal investigations and trials are forensic examinations. Look in the CPT® Index for Autopsy/Forensic Exam, and you are directed to 88040. 5. correct code(s) for this study? A B C. D. A patient with Acquired Immune Deficiency Syndrome (AIDS) presents for follow-up care. A total T-cell count is ordered to evaluate progression of the disease. What is the 86703 86360 86361, 86359 86359 Answer: D. 86359 in the CPT® Index for T-Cells/Count, which directs you to 86359. Rationale: Code 86359 is for total T-cell count. If other studies were performed, they were not ordered and may not be billed, no matter how seemingly appropriate. Look 16

Chapter 18: Pathology and Laboratory DOCUMENT DISSECTION CASE 1 Ordering Physician: & William Jones, MD Clinical Indications: 2 HCV. Liver function tests: Bili 0.6, alk phos 89, AST 40, ALT 59. Gross Description: & Received in formalin labeled “Smith, liver” are four needle core biopsy fragments ranging in size from 0.5 cm up to 1.4 cm in length. The specimens are entirely submitted in cassette A. Microscopic Description: ¥ The architecture is intact without nodularity, with approximately 16 portal tracts available for evaluation with no architectural distortion. There is minimal portal lymphocytic infiltrate, and mild focal portal fibrous expansion, confirmed by trichrome stain, = with no pericellular fibrosis. There is minimal focal lobular inflammatory activity. There is no steatosis. There are no iron deposits or hepatocyte intractyoplasmic globules identified by iron and PAS-D stains, ™ respectively. Final Diagnosis: & A) Native liver, core needle biopsy: 1. Chronic hepatitis with minimal focal portal and lobular activity and mild focal portal fibrous expansion, confirmed by trichrome stain, with hepatitis C induced disease, Grade 1, Stage 1 & 2. No steatosis 3. Noiron deposition detected by iron stain 4. No hepatocyte cytoplasmic inclusions detected by PAS-D stain 1 The name of the ordering physician must always be recorded as part of the documentation. H Although not strictly required, including any clinical indications when available is very helpful, especially when results are negative as this is the medical necessity for the service. £l Surgical Pathology services always require a gross description. This area also contains critical information regarding the number of specimens received. Bl Except for code 88300, surgical pathology codes require a microscopic examination. 2/ Notes must specify any special preparations used along with the findings associated with that preparation. First stain performed. = Another two stains performed. X The final diagnostic statement is key to coding surgical pathology services. This is the physician’s interpretation. E Knowing the procedure used to obtain the specimen is also key as this will be part of determining the right level of service. Bl The final diagnosis is both the physician work component and the diagnosis to be used to select an ICD-10-CM code. Note as well that the results of each separate stain and treatment are listed with their findings, even when the findings are negative. What are the CPT* and 1CD-10-CM codes reported? CPT® codes: 88307, 88312, 88313 x 2 1CD-10-CM code: B18.2 Rationale: CPT* codes: Code 88307 reports surgical pathology of one cassette of specimens of the liver from a core needle biopsy. Look in the CPT® Index for Surgical Pathology/Gross and Microscopic Exams/Level V. You may not know what Level it is (1I-VI): Look at codes 88302-88309, find Liver, biopsy—needle/wedge, 88307. Code 88312 reports the PAS-D stain. The trichome and iron stain are each reported with 88313. In the CPT* Index, look for Surgical Pathology/Special Stain or look for Smear and Stain/Blood Smears/Surgical Pathology directs you to 88312-88313, 88319. ICD-10-CM code: The diagnosis is chronic hepatitis type C. Look in the ICD-10-CM Alphabetic Index for Hepatitis/C (viral)/chronic B18.2. The Tabular List confirms code selection. 17

Chapter 18: Pathology and Laboratory CASE 2 Ordering Physician: ! Annette Brown, MD Cytology Report: ¥ Screening cervical Pap smear, Bethesda system Collected: 1/30/20xx ™' Received: 2/3/20xx Patient History: LMP: 1/24/xx Additional Information: Kidney transplant Specimen Source: A) Endo/Ecto cervical Cytologic Impression, Manual Screening with Physician Supervision: Negative for intraepithelial lesions or malignancy L Sampling Adequacy: Endocervical cells present. Comments: Menstrual sample. & As with surgical pathology, the ordering physician must always be documented as part of the report. El Although not always recorded as part of the report it is helpful to know what type of study was requested. This heading also tells us that the specimen was a Pap smear and that it was cervical rather than vaginal. Bl The date collected is the date of service. Bl Clinical data will be helpful in coding ICD-10-CM for negative results. =l Choosing a code includes know how the screening was performed. That information is included here. I This is the physician’s interpretation. It is the Bethesda reporting system. What are the CPT* and ICD-10-CM codes reported? CPT” code: 88164 ICD-10-CM codes: Z12.4, 794.0 CPT® code: The procedure is a manual screening of a cervical Pap smear. Look in the CPT® Index for Pap Smears/Bethesda System 88164-88167. Code 88164 is correct because the manual screening of the cervical smear was done under physician supervision. ICD-10-CM codes: Screening Pap smears are performed to diagnose cervical cancer and pre-cancer or dysplasia. Look in the ICD-10-CM Alphabetic Index for Screening/neoplasm (malignant) (of )/cervix Z12.4. The patient has had a kidney transplant. Look in the Alphabetic Index for Transplant{ed) (status)/kidney 794.0. Verify code selection in the Tabular List. 18

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Chapter 18: Pathology and Laboratory Glossary Autopsy—Examination of a dead body to determine the cause(s) of death (syn. necropsy). Bacteriology—Branch of science concerned with the study of bacteria. Cytopathology—The study of the cellular changes in disease. Cytogenetics—A branch of genetics concerned with the study of the structure and function of the cell, especially the chromosomes. Clinical Laboratory—Place where tests are performed on clinical specimens to get information about the health of a patient as pertaining to the diagnosis, treatment, and prevention of disease. Clinical Laboratory Improvement Amendments (CLIA)—Quality standards for all laboratory testing to ensure the accuracy, reliability, and timeliness of patient test results. CLIA Waived Tests—Simple tests that may be performed in non-laboratory settings, such as a physician office. Definitive Identification—Identification of the genus and species of the microorganism. Forensic—Pertaining to or applicable to personal injury, murder, and other legal proceedings. Gross—Examination of the entire specimen without sectioning of the specimen into thin slides to be examined without the use of a microscope. Hematology—The medical specialty pertaining to the anatomy, physiology, pathology, symptomatology, and therapeutics related to blood and blood forming tissues. Immunology—The study of the immune system, its components and function. In Vivo—Studies performed within the living body. Microbiology—The study of microorganisms, including fungi, protozoa, bacteria, and viruses. Microscopy (Microscopic)—Examination under a microscope of minute objects. Molecular Diagnostics—The measurement of DNA, RNA, proteins or metabolites to detect genotypes, mutations or biochemical changes. Mycology—The study of fungi, their identification, classification, edibility, cultivation, and biology, including pathogenicity. Necropsy—FExamination of a dead body and organs to determine the cause(s) of death (syn. autopsy). Panel—A group of tests performed together and listed in the code description. Pathology—The medical science and specialty practice concerned with study of diseased tissue and cells. Presumptive Identification—Identification of a microorganism based on the growth patterns, color, success in culturing the specimen in certain media, etc. Parasitology—The branch of biology and of medicine concerned with the study of parasites. Qualitative—A test determining the presence or absence of a drug. Quantitative—A test identifying not only the presence of a drug, but the exact amount present. Semi-quantitative—Test identifying the amount of an analyte within a specified range but does not identify a specific quantity. Virology—The study of viruses and of viral disease. 19

CPC Chapter 18

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