Pathology/Lab Coding Alert

The February 2003 Pathology/Lab Coding Alert reader question "Uterus and Ovaries To Bundle or Not to Bundle" should have stated that because the case involves a primary ovarian cancer with a separately diagnosed metastatic uterine carcinoma, you should report the service as 88307 (Level V Surgical pathology, gross and microscopic examination, ovary, with or without tube, neoplastic) for the ovary and 88309 (Level VI Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, neoplastic) for the uterus.

"Because hysterectomies often include incidental tubes and ovaries, CPT bundles them with the uterus," says Stephen Yurco III, MD, partner and pathologist at Clinical Pathology Associates in Austin, Texas. "But when the pathologist must separately examine tubes and ovaries because of pathology, they are no longer incidental to the uterus, and you should code them separately.

"Coding uterus and ovaries often requires a judgment call, and you have to be very careful not to unbundle capriciously," Yurco says. For example, if a complete hysterectomy yields an ovary showing only minor pathology, such as a few nests of endometriosis, the ovary would not warrant reporting an additional service.