Special Report
Lymph Node Coding in Surgical Pathology
Izak B. Dimenstein, MD, PhD, HT(ASCP)
(Loyola University Chicago Medical Center, Maywood, IL)
DOI: 10.1309/BR9X9WXBEMDL8Q68
Lymph nodes are the most complicated subject for coding in surgical pathology. There are sometimes controversial
recommendations how to code lymph nodes using CPT (Current Procedural Terminology). Although some of the ambiguity is created by AMA Editorial Board Panel’s reluctance to
provide more options that reflect clinical practice, the adherence to the spirit of CPT can offer the necessary guidance.
The unit of coding/charge is the “specimen.” According
to CPT, “A specimen is defined as tissue or tissues that is (are)
submitted for individual and separate attention, requiring individual examination and pathologic diagnosis.” Although the
rules of coding require mandatory bundling of some “specimens” even when they are submitted in separate containers
(for example, mesenteric lymph nodes in colon resection or
one/many lymph nodes in larynx resection), in practice it is
impossible to separate them at the accession stage because the
computer programs for accession and coding/charge are designed by one container one specimen rule. This rule helps to
maintain the general order in surgical pathology, especially
while processing the specimens in the grossing room.
Codes
Current procedureal terminology provides 2 codes regarding lymph nodes: Lymph Node, Biopsy, Level IV 88305
and Lymph Node, Regional Resection, Level V 88307.The
recently added Sentinel Lymph Node, is also Level V 88307.
There is no problem with the latter unless it is not included
in the computer dictionary or the accession person/billing
manager overlooks the sentinel node denotation. For example, breast lumpectomy with sentinel and non-sentinel lymph
nodes. It means that they are accessioned as Level V and
Level IV.
The definition of “Lymph Node, Regional Resection” is
the main difficulty in lymph node CPT coding. Procedural
versus arithmetical approach to the specimen assessment is the
core of the problem.
The Current Procedural Terminology “is a systematic
listing and coding of procedures and services performed by
physicians” states the first line of the introduction. “CPT procedure terminology has been developed as standalone descriptions of medical procedures” is reiterated elsewhere in the
introduction. Divergence from the procedure approach complicates charge coding in surgical pathology.
For example, the available on line SPECIMEN TO
CHARGE CODE RAPID FINDER LIST hosted by University of Michigan Health System (a very reliable source for
CPT coding in surgical pathology) has, in my view, a wrong
recommendation regarding lymph node coding. In
Definitions & Specimen Assignments section (page 5, point
2) is written: “Two or more lymph nodes from the same anatomic
site constitute a “regional resection” for charge classification.” This
categorical statement is a simplistic arithmetical approach.
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Discussion
The amount of lymph nodes does not represent
“regional resection” but the nature of surgical action does.
The surgeon removes a fragment of adipose tissue with presumably 1 or a group of lymph nodes inside because lymph
nodes are not visible as grapes on a branch. How many
lymph nodes are in this adipose fragment depend on many
conditions. There can be some variants: 1 very good circumscribed, 2 or more different sizes in different stages of the
capsule formation, and finally not any, but adipose more or
less fibrous tissue. The surgeon did her best to take the
lymph nodes out. The pathologist tried to reveal as much as
possible of the lymph nodes. An open secret is that the
amount of discovered lymph nodes depends also on the diligence and experience of the grossing person. It is obvious
that only 1 lymph node or even the absence of any does not
change the nature of the procedure that is coded and eventually charged. Although it is easier for coders to have a simple
rule: 1 lymph node – biopsy (88305), two or more in the
same specimen – “regional resection” (88307), this simplification does not serve the purpose of correct coding. If the
lymph nodes are not intended to be taken out from a region
in a packet, they are biopsies. In the situation of a
block/packet removing even one or no lymph node constitutes “regional resection.”
Let us take an example of radical prostatectomy with
lymph nodes from different areas (obturator, iliac artery, etc).
The lymph nodes are placed, of course, in different containers. In essence, the surgical procedure is a regional resection,
but each specimen is a lymph node biopsy as far as coding is
concerned. Often lymph nodes are taken out in packets during radical prostatectomy as right external iliac and obturator
lymph nodes and left pelvic lymph nodes. They are placed in
2 containers. In my opinion, the definition of regional resection can be applied in this situation.
Here comes the tricky part. According to CPT, “Larynx,
Partial/Total Resection – with Regional Lymph Nodes” is
Level VI 88309. Another example is the definition “Breast,
Mastectomy –with Regional Lymph Nodes” (the axillary tail).
The first situation is rare because usually they are submitted
separately. The second is common because the breast is usually
submitted with the axillary tail as 1 specimen. Both, however,
have nothing to do with code 88307 Level V – Lymph Node,
Regional Resection. They are code Level VI 88309. If the larynx is submitted without lymph nodes it is Level V 88307.
We are moving in the gray area when during a partial
mastectomy some levels of axillary dissection are performed
with presumably groups of lymph nodes. The axillary dissection 1 or 2 depends on the relation to the pectoralis minor
muscle. Although this is not a regional resection by the letter
of the CPT definition (many “regions” in 1 axillary region), it
would be right to consider them as Level V 88307 due to the
spirit of the procedure.
labmedicine.com
Special Report
The lymph node for lymphoma workup coding requires
separate discussion. This procedure becomes more and more
routine in surgical pathology practice. There are different protocols of lymphoma workup depending on the size of the
specimen. Most institutions include a regular histology, touch
imprints, flow cytometry, snap freeze for molecular biology
studies, cytogenetics for chromosomal analysis. In general,
lymphoma workup is a time consuming and demanding procedure because the specimen arrives fresh and requires immediate actions. Most computer dictionaries consider lymphoma
workup as CPT Level V (88307) equalizing with “Soft Tissue
Mass (except Lipoma) –Biopsy/ Simple Excision.” It is time
for AMA’s Editorial Board Panel to include lymphoma
workup for lymph nodes in CPT as Level V 88307.
labmedicine.com
The lymph node coding requires understanding of medical issues by the accession person/billing manager and supervision by the resident/pathologist. There is a hope that AMA’s
Editorial Board Panel will clarify the lymph node CPT coding
by offering more options with definite limitations of their use.
More detailed discussion of lymph node coding along
with other questions of CPT coding can be found on the Web
site www.chargecodepathology.com.
Disclaimer: The use of this information will not prevent
dispute with any third-party payer. This information will bear
no liability for its application. LM
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