Pathology/Lab Coding Alert

Several missteps could cost you pay.

When your pathologist receives a uterine specimen for suspected fibroids, do you have the tools to make sure you accurately code the case and capture all the pay you deserve?

Read on for our experts’ tips to ace your uterine fibroid coding, every time.

Coder glossary: You might find uterine fibroids going by many aliases in a pathology report. A fibroid by any of the following names is still a fibroid: leiomyoma, leiomyofibroma, fibroma, myoma, myofibroma, fibromyoma, or fibroid tumor.

Tip 1: Distinguish Uterus or Fibroid Specimen

Reading the pathology report to assign procedure codes, the first thing you need to determine is whether the pathologist received a specimen consisting of leiomyoma(s) or the entire uterus with leiomyoma(s).

If the pathologist identifies a hysterectomy specimen, you should code the case as 88307 (Level V - Surgical pathology, gross and microscopic examination … Uterus, with or without tubes and ovaries, other than neoplastic/prolapse …).

Say what? Don’t be confused by the fact that a leiomyoma is a benign neoplasm — that doesn’t mean you should report this case as 88309 (Level VI - Surgical pathology, gross and microscopic examination … Uterus, with or without tubes and ovaries, neoplastic …). By coding convention reinforced by College of American Pathologists (CAP) and CPT^® instruction, you should report a uterus with fibroids as 88307 rather than 88309. Endorsing this coding exception is due to the fact that uterus specimens commonly contain fibroids, yet the pathology exam requires far less work than a uterus with a malignant neoplasm.

If the pathologist receives a fibroid specimen that is not part of a hysterectomy, you should not report 88307, but should instead turn to 88305 (Level IV - Surgical pathology, gross and microscopic examination … Leiomyoma(s), uterine myomectomy - without uterus …). If that’s the case, you need to turn to the next tip to make sure you don’t leave money on the table.

Tip 2: Identify Multiple or Distinct Specimens

Let’s say the pathologist examines two large specimens in the same container submitted by the surgeon as suspected fibroid tumors. The pathologist prepares two cassettes and examines multiple slides from each tumor — how should you code?

First of all, remember that size doesn’t matter — a fibroid is a fibroid no matter how large the growth. But if you said 88305 x 2 because there are two fibroids, you would be wrong. Number doesn’t matter either — notice that the code definition states “leiomyoma(s),” and that little “(s)” means you should report just one unit of 88305, even if the pathologist examined two fibroids.

Caveat: “Sometimes the surgeon separately identifies and submits distinct fibroid specimens,” says R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services in Jonesboro, Ark. When the pathologist then separately examines the distinctly identified fibroids, you may report multiple units of 88305.

Two diagnoses: Rarely, special circumstances may warrant multiple units of 88305, even for fibroids submitted as a single specimen. For instance, if the pathologist examines two uterine masses and diagnoses one as a leiomyoma and the other as a uterine polyp, that means you’re coding for two distinct procedures. You may report the procedure as 88305 (… Leiomyoma(s), uterine myomectomy - without uterus …) and a second unit of 88305 (… Polyp, cervical/endometrial …) in this case.