Kari -

Please note that this communication is one from a bias of being a fellowship 
trained GI/Liver pathologist with roughly 55,000 GI/liver case experience 
over the last six (6) years.

A Giemsa or other special stain is sometimes necessary to identify H. pylori 
- an infection of the stomach that has specific OTHER histologic 
characteristics on H&E stain.  Sometimes, you can see H. pylori on an H&E.

The important thing to recognize is that IF those other features aren't 
there - then the H. pylori won't be either.

In the roughly 15,000 gastric biopsies that I have reviewed, about 7500 of 
them had special stains done "from the bench," and the remaining 7500 I 
ordered a special stain if I suspected that there was H. pylori or if a 
"threshold" was crossed.

My personal thresholds: (1) any active inflammation with accompanying plasma 
cells > than 3/interfoveolar space [even if Ithink it's reactive gastropathy 
with active inflammation - as is seen in bile reflux, NSAIDs and others]; 
(2) ten or greater plasma cells per interfoveolar space even without active 
inflammation - in the antrum; (3) six or greater plasma cells per 
interfoveolar space even without active inflammation - in the body of the 
stomach; (4) any intestinal metaplasia - that is clearly not junctional 
pylorus sampling.

Anectodally, I have only been surprised by ONE H. pylori stain... in about 
15,000 cases... and it ws a case that met my threshold - but barely.  About 
5% of the cases with the threshold above DO demonstrate H. pylori.  These 
are what many pathologists would call "unsuspected" H. pylori - however, 
once you know the various patterns that H. pylori can show - in addition to 
the standard "chronic active gastritis" then the stains can be performed in 
a directed fashion... eliminating about 70% of all H. pylori stains done 
from the bench.  In all of the "from the bench stains" that I expected to be 
negative - they were negative.

If the clinician writes "r/o H. pylori" - that doesn't REQUIRE a pathologist 
to do a Giemsa stain.  A comparison:  if a patient has an iron deficiency 
anemia and the primary care doctor writes "Rule out colon cancer" on the 
consultation request - that doesn't REQUIRE the gastroenterologist to take a 
biopsy of NORMAL COLON if there is no mass there.

Julia Dahl, M.D.
Gastrointestinal and Hepatic Pathologist
Mosaic Gastrointestinal Research Consortium


>From: "Zajic Kari" 
>To: "Richard Cartun" 
>,, "Brandi Farris" 
>
>Subject: RE: [Histonet] Billing question
>Date: Thu, 7 Sep 2006 09:31:42 -0400

>
>99% of the time our biopsies are ordered with R/O H.Pylori from the GI doc 
>in which we prove or disprove with the Giemsa stain.
>I don't know, not my call but I'd sure want one and would pay for one if I 
>was having a stomach biopsy!
>I guess it's facility-wide call...it happens to be a policy here put in 
>place by the Medical Director and he's very "old-school", we even keep old 
>handwritten log books here since the inception of the hospital....lucky me. 
>hahaha
>
>Kari Marie Zajic HTL,MLT
>Histology Supervisor
>Palms West Hospital
>Pathology Department
>13001 State Road Eighty
>Loxahatchee, Florida 33470
>phone:      (561)798-6036
>telefax:     (561)753-4298
>voicemail: (561)753-4299
>pager:       (561)610-4949
>email: Kari.Zajic@HCAHealthcare.com
>
>This email and any files transmitted with it may contain PRIVILEGED or 
>CONFIDENTIAL
>information and may be read or used only by the intended recipient. If you 
>are not the intended recipient of the email or any of its attachment, 
>please be advised that you have received this email in error and that any 
>use, dissemination, distribution, forwarding, printing, or copying of this 
>email or any attached files is strictly prohibited. If you have received 
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>
>
>-----Original Message-----
>From: Richard Cartun [mailto:Rcartun@harthosp.org]
>Sent: Thursday, September 07, 2006 9:14 AM
>To: Zajic Kari; histonet@lists.utsouthwestern.edu; Brandi Farris
>Subject: RE: [Histonet] Billing question
>
>
>That's not the point.  The real question is, "Why are you doing it if
>it's not medically necessary?".
>
>Richard
>
>Richard W. Cartun, Ph.D.
>Director, Immunopathology & Histology
>Assistant Director, Anatomic Pathology
>Hartford Hospital
>80 Seymour Street
>Hartford, CT  06102
>(860) 545-1596
>(860) 545-0174 Fax
>
> >>> "Zajic Kari"  09/07/06 8:29 AM >>>
>We also bill for a Giemsa on all stomach specimens...if it's being
>performed, read and diagnosed out, why wouldn't you be able to charge
>for the work? Did he give you a reason? That's like saying oh, you can't
>charge for services done...
>
>Kari Marie Zajic HTL,MLT
>Histology Supervisor
>Palms West Hospital
>Pathology Department
>13001 State Road Eighty
>Loxahatchee, Florida 33470
>phone:      (561)798-6036
>telefax:     (561)753-4298
>voicemail: (561)753-4299
>pager:       (561)610-4949
>email: Kari.Zajic@HCAHealthcare.com
>
>This email and any files transmitted with it may contain PRIVILEGED or
>CONFIDENTIAL
>information and may be read or used only by the intended recipient. If
>you are not the intended recipient of the email or any of its
>attachment, please be advised that you have received this email in error
>and that any use, dissemination, distribution, forwarding, printing, or
>copying of this email or any attached files is strictly prohibited. If
>you have received this email in error, please immediately purge it and
>all attachments and notify the sender by reply email or contact the
>sender at the number listed.
>
>
>
>
>-----Original Message-----
>From: histonet-bounces@lists.utsouthwestern.edu
>[mailto:histonet-bounces@lists.utsouthwestern.edu]On Behalf Of Brandi
>Farris
>Sent: Wednesday, September 06, 2006 9:13 PM
>To: histonet@lists.utsouthwestern.edu
>Subject: [Histonet] Billing question
>
>
>Hello,
>
>Our hospital recently had an insurance/billing consultant give us some
>advice. We currently perform and bill for a giemsa stain (special stain
>group I) on all stomach and esophagus biopsy specimens. The consultant
>told us that we could no longer bill for those. What stain is everyone
>else doing and how are you billing it?
>
>Thanks
>Brandi Farris
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>
>
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