Pathology/Lab Coding Alert

Choose 1 macrodissection code based on primary procedure.

Don’t let the + sign confuse you -- +88388 does not mean you should report +88388 in addition to 88387 for multiple macrodissections.

Just in case you weren’t clear on that fact, Correct Coding Initiative (CCI) version 16.0 bundles 88387 (Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies [e.g.,nucleic acid-based molecular studies]; each tissue preparation [e.g., a single lymph node]) with +88388 (… in conjunction with a touch imprint, intraoperative consultation, or frozen section, each tissue preparation [e.g., a single lymph node] [List separately in addition to code for primary procedure]) starting Jan. 1.

Capture Pay for Molecular Diagnostics Tissue Prep

Pathologists have been prepping tissue for ancillary studies, such as molecular diagnostics, for as long as the tests have been available. But you have never had a code to capture your pathologist’s work -- until now.

Know primary procedure: You should choose 88387 or +88388 for the tissue prep based on the primary procedure.

List 88387 if the pathologist preps tissue from a pathology exam (88302-88309, Level II-VI -- Surgical pathology, gross and microscopic examination …) for an ancillary study such as molecular diagnostics.

“On the other hand, you should reserve +88388 for macrodissection associated with a primary procedure such as 88161 (Cytopathology, smears, any other source; preparation, screening and interpretation), 88329 (Pathology consultation during surgery), 88331 (… first tissue block, with frozen section[s], single specimen), or 88333 (… cytologic examination [e.g., touch prep, squash prep], initial site),” according to William Dettwyler, MTAMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore.

Follow CPT -- 88387 and +88388 Stand Apart

In addition to the code definitions, CPT 2010 includes text notes to help you correctly use 88387 and +88388:

• To ensure that you use +88388 with consultations, CPT states, “use 88388 in conjunction with 88329-88334)” and “do not report 88387 in conjunction with …88329-88334.”

• To make sure you select only one macrodissection code, CPT states, “do not report 88387 in conjunction with 88388.”

What does + mean? “CPT 2010 lists +88388 as an add-on code because you should only report it in addition to the primary touch prep or intraoperative consult,” Dettwyler clarifies.