Inpatient Facility Coding & Compliance Alert

Question: The pathologist examines a specimen that the surgeon labels “breast lumpectomy.” Additionally, the surgeon sends two more containers, each with a small fragment of breast tissue, one submitted as “medial margin,” and the other as “deep margin,” which our pathologist examines. Should we bill this as 88307 and 88305 x 2?

Pennsylvania Subscriber

Answer:  Based on the information provided, you could code this case as 88307 (Level V - Surgical pathology, gross and microscopic examination, Breast, mastectomy, partial/simple) and 88305 x 2 (Level IV - Surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins). 

If the pathologist specifically documents margin exam for the separately-submitted medial margin and deep margin specimens, you could code the case as 88307 x 3.

Margin rule: You should bill the lumpectomy as a partial mastectomy (88307) whether or not the pathology report mentions a margin exam, because it is a listed specimen at that code level. 

However, the code for examining an adjacent piece of breast tissue — effectively a biopsy or excision — depends on whether the pathologist documents a margin exam. CPT^® provides two different codes for breast tissue (other than mastectomy or mammoplasty):

·         88305 — Breast, biopsy, not requiring microscopic evaluation of surgical margins

·         88307 — Breast, excision of lesion, requiring microscopic evaluation of surgical margins

Caution: A lumpectomy specimen includes the margins, so you would expect submission of a separate lumpectomy margin to be uncommon. The surgeon may take an additional margin if he sees something suspicious, or if there’s some evidence (such as an intraoperative touch prep) that the additional specimen is necessary because a margin is not clear. 

AMA concurs: You’ll find the following documentation regarding separate breast specimens in CPT^® Assistant, July 1999: “Based on the surgical pathology guidelines in CPT^®, a specimen is defined as tissue or tissues submitted for individual and separate attention, requiring individual examination and pathologic diagnosis. Two or more such specimens from the same patient are each appropriately assigned an individual code that reflects the proper level of service. … if both breast specimens are submitted separately, and are examined and assigned a pathologic diagnosis, then it would be appropriate to report each specimen separately.”