Coding Error #2: Not Knowing when to Separately Code for Multiple Specimens

This coding tip relates to how specimens are handled and processed in the histology laboratory. AMA procedural terminology states that 2-tissue specimens from the same patient (but separately identified, such as with endoscopic biopsies, skin lesions, etc.) are each appropriately assigned an individual code reflective of the proper level of service. This is a basic element of accurate coding. But it is easily overlooked in situations where multiple samples of the same type, but different areas, of the same patient are given the same code. In this situation, there could be some instances where the codes may be the same, but the specimens should still be kept separate.

Let us consider two cases. In one case, coding was not done properly, causing the samples to be rendered useless. In the other, coding was done properly and diagnosis was possible. In the first case, a sample from the right and left segments of a normal cross-section of a fallopian tube are delivered to the lab. The lab performs tests, inks one of the samples black, and returns them in one container with one label to the doctor who requested the lab work. There is no longer any designation as to which side of the fallopian tube from which the specimens came. Thus, the physician cannot process the lab work and make a proper diagnosis. Now, the invasive procedure and lab work have to be re-done so that the doctor can determine which segment was which and if there was a problem with one or both segments.

In the second case, the lab receives specimens of a left and right tonsil. The lab codes and designates the two samples separately (although with the same code number – 88304). The right tonsil is inked black, and both tonsils are returned to the physician who ordered the tests. A proper diagnosis can be made, no tests need be re-run, and billing the insurance company for lab work goes smoothly due to proper coding.

Perhaps the idea of mixing up specimens as was done in the first case seems unfeasible, but it only takes one coding oversight to end up with specimens mislabeled, combined, or otherwise rendered useless. That is a negative outcome that affects patient care and the pathologists’ relationship with the referring clinician, particularly if new specimens must be collected. The pathology laboratory that pays careful attention to keeping specimens separated – and codes and tests each one properly – can escape embarrassing and costly mistakes.