Pathology/Lab Coding Alert

Question: Our pathologist examines many specimens of bones, joints, and various bony fragments from an orthopedic practice. Especially when we receive fragments of bone, possibly in different containers, we're often uncertain how to apply the bone and joint pathology exam codes. For instance, does the femoral head from a hip replacement count as a joint replacement specimen? Please provide some rules for how to choose the proper code for these cases.

Florida Subscriber

Answer: Pathology codes for bone and joint exams can be quite challenging because you have so many codes to choose from. The choice is important, partly because the reimbursement for these pathology exam codes ranges from $42.94 for 88304 to $432.07 for 88309 (2024 Medicare Physician Fee Schedule national facility rate, conversion factor 33.2875). Here are some steps you can take to help you select the right code and ensure proper pay.

First: Familiarize yourself with the following code choices, and notice that a single code may represent more than one type of bone specimen:

• 88304 (Level III - Surgical pathology, gross and microscopic examination, … Bone fragment(s), other than pathologic fracture … Femoral head, other than fracture, … Joint, loose body …)
• 88305 (Level IV - Surgical pathology, gross and microscopic examination     Bone marrow, biopsy … Bone exostosis, … Femoral head, fracture, … Joint, resection …)
• 88307 (Level V - Surgical pathology, gross and microscopic examination … Bone - biopsy/curettings, Bone fragment(s), pathologic fracture …)
• 88309 (Level VI - Surgical pathology, gross and microscopic examination, Bone resection …)

Next: Pay attention to the ordering surgeon’s description of the specimen and select the code that most accurately and completely describes the listed specimen, assuming that the pathology report concurs.

For instance, if the surgeon identifies the specimen as a total knee resection, code the pathology exam as a joint resection, even if the pathologist receives the tissue in fragments or multiple containers. The correct code choice in this case would be 88305 (… Joint, resection …). Don’t report 88304 (… Bone fragment(s), other than pathologic fracture …) even if the joint arrives in pieces.

On the other hand, if the surgeon states that the tissue is a femoral head from a hip replacement surgery not involving a broken hip, you should code 88304 (… Femoral head, other than fracture …), not 88305 for joint resection. Hip replacement typically involves removing the femoral head and grinding down the acetabulum, but if your pathologist receives both parts of the hip joint, you should report a joint resection tissue exam, not a femoral head tissue exam.

Notice that CPT^® distinguishes between bone fragment specimens from pathological fractures and bone fragment specimens from other types of fractures. You'will look to 88304 for bone fragments due to nonpathological fractures, or 88307 for bone fragments due to pathological fractures such as cancer that has metastasized to bone. Similarly, you’ll need to distinguish between femoral head specimens based on whether the specimen is fractured (88305) or without fracture (88304).

Also, notice biopsy distinctions and report a bone marrow biopsy as 88305 (… Bone marrow, biopsy …) but a bone biopsy as 88307 (… Bone - biopsy/curettings …). Bone curettings are scrapings from a bone lesion.

Finally: Don't use a bone code if a more specific code exists. For example, you should report an amputated toe specimen for a condition such as osteomyelitis using 88305 (… Fingers/toes amputation, non-traumatic …), not 88309 (… bone resection …). Another example involves bone exostoses, which are benign growths of bone tissue formed on the surface of a bone that may occur in the ear, under the nail bed, in the sinus, or near joints. But in a case where the pathologist receives a mixed specimen from sinus surgery that includes bone fragments, mucosa and subcutaneous tissue, the proper description is 88305 (… sinus, paranasal biopsy …) not bone exostosis.

Ellen Garver, BS, BA, Contributing Writer