Pathology/Lab Coding Alert

Don't let bundling and diagnosis quirks ambush your leiomyoma claims.

If you're reporting your pathologists' fibroid exams, you need to know a thing or two (or three) about CPT® and ICD-9 roadblocks and opportunities. To make your job easier, our experts will help you zero in on proper code choices before the next uterine leiomyoma case lands on your desk.

Distinguish With/Without Uterus

When your pathologist examines uterine fibroids, the specimen will most often be from a hysterectomy procedure. That's because hysterectomy is the most common surgical treatment when fibroids are causing problems such as abdominal pain or heavy bleeding, according to Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M. "Bleeding recurrence is common if the physician doesn't remove the uterus," she says.

Not always: Sometimes, however, such as the case of a younger woman who still wants to have children, the physician will remove only the fibroids (myomectomy) and leave the uterus intact.

Pathology coders need to know the distinction because you'll choose between the following two codes for your pathologist's work depending on whether the specimen is with or without the uterus:

• 88305 -- Level IV -- Surgical pathology, gross and microscopic examination; Leiomyoma(s), uterine myomectomy, without uterus.
• 88307 -- Level V -- Surgical pathology, gross and microscopic examination; Uterus, with or without tubes and ovaries, other than neoplastic/prolapse

Based on "(s)" in the 88305 code definition, you should report one unit of 88305 for multiple fibroids submitted by the surgeon. In rare cases, the surgeon might separately identify and submit distinct fibroid specimens, and you can list multiple units of 88305 in those instances if the pathologist separately examines and diagnoses the specimens.

Don't unbundle: "When the pathologist examines a uterus with leiomyomas, you should code only 88307, not 88307 for the uterus plus 88305 for the fibroids," says R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark. Even if the pathologist dissects the fibroid tumor from the uterus and provides a separate diagnosis, you must bundle the leiomyoma with the uterus for CPT® reporting purposes.

Rarely: If the surgeon performs a myomectomy, and for some reason expands the procedure to a hysterectomy, he will likely separately submit the two specimens. In those rare cases, you can report 88307 for non-neoplastic uterus and 88305 for the fibroid if the op report and pathology report document two distinct specimens and diagnoses.

Don't Let Other Uterus Codes Confuse You

You should report 88307 for a uterus with a diagnosis other than neoplasm or prolapse. In other words, 88307describes the pathologic exam for a diagnosis code such as 617.0 (Endometriosis of uterus).

For other findings, you'll report one of the following codes for the pathologist's exam of a hysterectomy specimen:

• 88305 -- ... Uterus, with or without tubes and ovaries, for prolapse Use this with ICD-9 codes such as 618.1 (Uterine prolapse without mention of vaginal wall prolapse), 618.2 (Uterovaginal prolapse, incomplete),  18.3 (... complete), and 618.4 (... unspecified).
• 88309 --evel VI --rgical pathology, gross and microscopic examination; Uterus, with or without tubes and ovaries, neoplastic

Report this code if the pathologist finds neoplasia such as 179 (Malignant neoplasm of uterus, part unspecified), 233.2 (Carcinoma in situ of otherand unspecified parts of uterus), 219.x (Other benign neoplasm of uterus), or 236.0 (Neoplasm of uncertain behavior of uterus).

Bottom line: You might use 88305, 88307, or 88309 to bill for the pathologist's exam and diagnosis of a hysterectomy or myectomy depending on the specimen submitted and the final diagnosis.

Beware Neoplasia/Leiomyoma Quirk

Uterine leiomyoma is a neoplasm, according to ICD-9. But you shouldn't report every benign neoplasm using the general benign neoplasm code for that body site, 219.x. "Choose the code based on the specific description from the pathology report, such as fibroid tumor," Witt says.

According to David Glassman, DO, FACOG, medical director of Biltmore Women's Health and Aesthetics and assistant program director at the department of obstetrics and gynecologyresidency at Banner Good Samaritan in Phoenix, you should report a fibroid tumor with one of the following codes, based on characteristics such as type and location (the fourth digit):

• 218.0 --Submucous leiomyoma of uterus
• 218.1-- Intramural leiomyoma of uterus
• 218.2 --Subserous leiomyoma of uterus
• 218.9 -- Leiomyoma of uterus, unspecified.

Contradiction: So leiomyoma is a neoplasm, but you shouldn't report the pathologist's work as 88309 -- what gives?

Based on coding direction from the American Medical Association (AMA) and the College of American Pathologists (CAP), you should code the pathologist's exam of a hysterectomy specimen with fibroids as 88307, not 88309. That's true even though leiomyoma is a neoplasm. The AMA, in the December 2003 CPT® Assistant, states that "leiomyomas do not require the same degree of evaluation as other uterine neoplasms," and therefore concludes that when leiomyoma of the uterus is the principal diagnosis for a hysterectomy specimen, you should report 88307 rather than 88309.

Similarly, CAP has also published coding advice indicating that you should use 88307 for uterine leiomyoma, as well as for non-neoplastic uterine conditions (CAP Today July 1999).