88305 Tissue exam by pathologist - $76
procedure code 88305 describes level IV surgical pathology, gross and microscopic examination. When the operating provider or pathologist examines multiple, separate tissue samples on the same date of service for the same patient, the procedure code is reported using either multiple units or line items and may include any appropriate modifier(s). When the tissue samples are for prostate tissue, HCPCS lists procedure codes G0416-G0419 for 10 or more specimens in various increments for prostate needle biopsy. Therefore, the Health Plan will apply a frequency limit of nine units per date of service for procedure code 88305 when reported with a prostate diagnosis. When procedure code 88305 is reported in excess of nine units on the same date of service with a prostate diagnosis, the code will not be eligible for reimbursement.
Proper billing of procedure code 88305
Therefore, if an “E” code or V00-Y99 range ICD-10 CM diagnosis code is the first listed diagnosis code on the CMS-1500, the claim would not conform to the ICD-9-CM code set and electronic transmission of the electronic claim to a Coordination of Benefits Agreement (COBA) trading partner would not be Health Insurance Portability and Accountability Act (HIPAA) compliant.
Anthem Central Region bundles 88302, 88304, 88305, 88307 and 88309 as redundant/mutually exclusive with 88321, 88323 and 88325. Based on the Correct Coding Edits for Comprehensive Code 80000-89999; codes 88302, 88304, 88305, 88307 and 88309 are listed as component codes to codes 88321,88323, 88325. Based on procedure Assistant article:
“Also included in codes 88311 through 88365 are three codes for consultation and report on material referred from another source (i.e., referred from another pathologist or facility). These codes are appropriate for use in reporting consultation provided to another pathologist in a different practice site or facility or in reporting consultations to another physician in the same facility/site on material referred from an outside source (e.g., review of slides from another restitution prior to surgery or therapy at your facility
• Code 88321 is used to report a consultation on a referred slide(s) from a specimen
• Code 88323 is used to report a consultation on a specimen when the consultant prepares a slide(s) for routine histologic staining
• Code 88325 is used for a more comprehensive consultation on referred material that involves review of records and specimens
Therefore, when a pathologist is reviewing a specimen they are providing either the initial surgical pathology or acting as a consultant at the request of someone else. They cannot perform both services on the same specimen on the same date of service. If 88302, 883204, 88305, 88307 or 88309 is submitted with 88321, 88323 or 88325—only the consultation (88321, 88323 or 88325) reimburses.
The Identified Coding Problems
During an audit of the procedure codes associated with MMS across several states in a region, Medicare Recovery Auditors found instances in which the preparation and/or interpretation of the slides of tissue removed during the procedures was performed by someone other than the surgeon (or his/ her employee). Examples of findings from this audit follow:
• Example 1: A physician billed procedure Code 17311 (Mohs Micrographic Surgery), while on the same date of service procedure Code 88305 (Surgical Pathology, gross and microscopic examination) for the preparation and interpretation of the slides taken during the procedure, was separately billed for a specimen examination by a different practitioner without a modifier.procedure Code 17311 was, therefore, an overpaid claim.
• Example 2: A physician billed procedure Code 17313 (Mohs Micrographic Surgery) while on the same date of service procedure Code 88305 (Surgical Pathology, gross and microscopic examination) for the preparation and interpretation of the slides during the procedure was separately billed for a specimen examination by a different practitioner without a modifier. procedure Code 17313 was, therefore an overpaid claim.