New Provider and Reappointment Training Pathology Coding March 2019

Course Objectives Review basic principles of coding and documentation of pathology services Review resident/fellow supervision and documentation requirements for Medicare, Medicaid and TRICARE

Coding and Documenting Pathology Services

Documentation for Cytopathology Services The documentation should include (as applicable): Clinical history Specimen source Type of specimen Special stains, including positive or negative results Preparation of additional slides Preliminary results Reference results of all additional studies The diagnosis for each specimen CPT © 2019

Documentation for Surgical Pathology Services The documentation should include (as applicable): Clinical history Itemization of each specimen received and analyzed Specimen source Gross description Microscopic description Special stains, including positive or negative results Reference results of all additional studies Reference/results of all consults and frozen sections The diagnosis for each specimen CPT © 2019

Clinical Pathology Consultations Clinical consultations are paid under the Medicare Physician Fee Schedule (MPFS) only if they: a. Are requested by the patient’s attending physician; b. Relate to a test result that lies outside the clinically significant normal or expected range in view of the condition of the patient; c. Result in a written narrative report included in the patient’s medical record; and d. Require the exercise of medical judgment by the consultant physician. Routine conversations held between a laboratory director and an attending physician about test orders or results do not qualify as consultations unless all four requirements are met. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

Clinical Pathology Consultations CPT 80500 – Clinical pathology consultation; limited, without review of patient's history and medical records CPT 80502 – Clinical pathology consultation; comprehensive, for a complex diagnostic problem, with review of patient's history and medical records Reporting of a test result(s) without medical interpretive judgement is not considered a clinical pathology consultation. CPT © 2019

Anatomic or Surgical Pathology Consultations When pathologists refer cases to each other for second opinions on anatomic or surgical pathology tests, it is imperative to document appropriately. The documentation should indicate whether the slides were prepared elsewhere (CPT 88321) or required preparation (CPT 88323). If the consulting pathologist needs to review previous medical records and specimens in order to render an opinion, this must be explicitly noted in the documentation (CPT 88325). Intraoperative pathology exam – When a pathologist is consulted during a surgery to render an opinion on the presence or absence of diseased or abnormal tissue provided (gross examination without concurrent microscopic examination), CPT 88329 may be used. CPT © 2019

Modifiers That Impact Payment Modifier 91 – Repeat Clinical Diagnostic Laboratory Test In the course of treatment, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91. This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.

Diagnosis Coding Tests ordered due to signs and/or symptoms: If the physician has confirmed a diagnosis based on results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis. The definitive diagnosis code should be sequenced before the symptom code. If the diagnostic test did not provide a diagnosis or the diagnosis was normal, the interpreting physician should code the sign(s) and/or symptom(s) that prompted the treating physician to order the study. Always code to the highest level of specificity possible. https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf

Diagnosis Coding Tests ordered without a definitive diagnosis or signs/symptoms: If the results of the study are normal or non-diagnostic, and the referring physician records a diagnosis preceded by words that indicate uncertainty (e.g., probable, suspected, questionable, rule out, or working), then the interpreting physician should not code the referring diagnosis. Rather, the interpreting physician should report the sign(s) and/or symptom(s) that prompted the study. On the occasion when the interpreting physician does not have diagnostic information as to the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient’s medical record if it is available. However, an attempt should be made to confirm any information obtained from the patient by contacting the referring physician. https://www.cdc.gov/nchs/data/icd/10cmguidelines_fy2018_final.pdf

Teaching Physician Guidelines

Medicare Teaching Physician Guidelines Medicare pays for the interpretation of diagnostic tests if the interpretation is performed by or reviewed with a teaching physician. If a resident prepares and signs the interpretation, the teaching physician must indicate that he or she has personally reviewed the specimen and the resident’s interpretation and either agrees with or edits the resident’s findings. The resident should not document the participation of the teaching physician. Co-signature of a resident's interpretation alone is not sufficient for billing Medicare. Acceptable Attestation for Medicare: “I have personally reviewed the specimen and the resident’s interpretation and agree with the findings as documented by the resident. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

North Carolina Medicaid Requirements The degree of supervision is the responsibility of the teaching physician and is based on the skill, level of training, and experience of the resident as well as the complexity and severity of the patient's condition. Written documentation in the medical record for Medicaid patients must clearly designate the supervising physician and be signed by that physician.

TRICARE Teaching Physician Requirements Documentation of supervision must be entered into the medical record by the supervising practitioner or reflected in the resident progress note or other appropriate entries in the medical record (e.g., procedure reports, consultations, discharge summaries) Pathology reports must be verified by a supervising practitioner. Co-signatures are required unless the Resident documents the name of the supervising practitioner with whom the case was discussed, a summary of the discussion, and a statement of the supervising practitioner’s oversight responsibility for the assessment, diagnosis, plan for evaluation, or treatment. Acceptable Attestation for TRICARE: “I have personally reviewed the specimen and the resident’s interpretation and agree with the findings as documented by the resident. For the purposes of meeting TRICARE guidelines, UNC will use the same attestations for both Medicare and TRICARE regarding TP supervision.

Contact Us EMAIL AND WEBSITE ProComplianceUNCHC@unchealth.unc.edu http://www.med.unc.edu/compliance https://unchcs.intranet.unchealthcare.org/dept/ACP DIRECTOR Robin Davis Shuping, RN, MHA, CPC | System Director, Professional Compliance – UNC Health Care Hedrick Building, Suite G050 211 Friday Center Drive Chapel Hill, NC 27517 Ph (984) 974-1017 | Fax (984) 974-1307 Robin.Shuping@unchealth.unc.edu ASSOCIATE DIRECTOR Laura Bushong, MSJ, CPC, CHC | Associate Director Professional Compliance – UNC Health Care Hedrick Building, Suite G063 211 Friday Center Drive  Ph (984)974-1107 | Fax (984)-215-2948 Laura.Bushong@unchealth.unc.edu