It allows us to bill for all services provided and ensure being reimbursed for said services. If it’s not documented, we can’t bill for it. We do go back to our providers and ask for addendums when we find that CPT codes are noted on a report, but not documented. This often comes up when we onboard new clients and it’s a great value-added process.
Documentation and reports are also critical to fall back on if a payer asks for an audit. It must validate the services billed or the payer will ask for money back if they paid for services that the documentation doesn’t support.
Probably the most common issue is when we appeal for denied services. The documentation is always sent with the appeal documents so it must clearly outline the services and show medical necessity.
Common Issues
Clear documentation is often lacking for frozen, IHC & evaluation episodes. Here is more information:
Frozen Section
Documenting frozen section service is important for correct coding. Not documenting each individual block, along with findings, is a missed opportunity for assigning correct CPT & units to each service.
The formal CPT code book descriptors for the codes are:
- 88331: Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen and
- 88332: Pathology consultation during surgery; each additional tissue block with frozen section(s)
The primary unit of service for frozen section is the specimen, but equally important from a coding perspective is the secondary unit of service, which is the tissue block. The first tissue block from each specimen that is microscopically examined and diagnosed by frozen section gets its own 88331 code; if more than one block from a specimen is prepared and examined by frozen section, each additional block is coded 88332. In other words, each different specimen that is evaluated by frozen section gets one (and only one) 88331 charge, but if multiple tissue blocks are evaluated for a specimen, each block beyond the first is reported with code 88332. Document each block separately.
For example, report findings for each block:
AFS1 – 88331
AFS2 – 88332
AFS3 – 88332
BFS1– 88331
BFS2– 88332
Immunohistochemistry “IHC” Stain
Providing clear IHC stain documentation is important to the treating physician, and for billing & coding purposes. Documentation should include:
- Reason for ordering IHC stain(s) to support medical necessity
- Name of each antibody and block assignment
- Consider adding a ‘grid’ to the report listing each stain, block and finding
By providing this information (1-3), it helps summarize findings for the clinician and gives information for correct coding. It provides the biller clean documentation for appeal and audit requests by the payer.
Grid Examples:
Fine Needle Aspiration and Touch Imprint: Documenting Immediate Evaluation Episodes/Adequacy
The unit of service for an immediate review of an FNA or touch imprint during an intraoperative procedure is defined as the evaluation episode. An episode refers to when the pathologist reports the adequacy assessment to the clinician for a specific site. Use 88172 for the first adequacy assessment for a specific site and 88177 for each additional adequacy assessment involving that same site. For touch imprint, use 88333 and 88334 for each additional episode.
The key to note in documentation is that a "pass" does not necessarily constitute an episode. A "pass" refers to the collection of a specimen. The clinician might make multiple "passes" before the pathologist performs an adequacy check on those passes. The immediate review of multiple passes for a specific site and reporting the findings back to the clinician would encompass an evaluation episode. Strong documentation should include a time stamp along with the results of the assessment and the physicians' name for each evaluation episode performed.
Example: On this case, part A is FNA and part B is core needle biopsy:
- 88172
- 88333, 88334
Note time of day is documented, which separates each episode
We never doubt that services coded weren’t provided, but if the documentation doesn’t support it, we can’t bill for it.
We hope these examples help to shed some light onto the necessity and the challenges we face. With more and more payers looking for ways to deny claims or recoup money already paid, we have to always try to be a step ahead of them.