Pathology/Lab Coding Alert

See how many specimens you have.

Now that you’ve decided how to code the case described on page 76, read on to see how you did.

Capture Multiple Specimen Exam Codes

If you picked the CPT^® code for myomectomy (88305, Level IV - Surgical pathology, gross and microscopic examination, … leiomyoma(s), uterine myomectomy - without uterus …) instead of for uterus with fibroids (88307, Level V - Surgical pathology, gross and microscopic examination … Uterus, with or without tubes and ovaries, other than neoplastic/prolapse …), you’re on the right track.

But the second hurdle in properly assigning the procedure code(s) for the pathologist’s work involves one little “s” in the code definition. You can see that the 88305 descriptor states, “leiomyoma(s),” so you typically should report one unit of 88305 for multiple fibroids submitted by the surgeon.

“Occasionally, however, the surgeon might separately identify and submit distinct fibroid specimens,” explains R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services in Jonesboro, Ark. In those instances, you can list multiple units of 88305 if the pathologist separately examines and diagnoses the specimens.

Do this: Because the case at hand involves two, separately-identified and submitted fibroid specimens that the pathologist individually examines — one from the cervix and one from the fundus — you should bill 88305x2 for the service.

Caution: The pathologist received the two cervical fibroids together in one container with no distinguishing marks or direction from the surgeon, so you must bundle those as one unit of 88305. The other unit of 88305 represents the separately-submitted myoma specimen from the uterine fundus.

Drill Down for Specific ICD-10 Codes

To choose the most specific diagnosis code for these specimens, you need to understand some basics about uterine fibroids, also called leiomyomas. Classification of these tumors depends on where the growth originates. The three main locations parallel the diagnosis codes, as follows:

• Submucous fibroids originate in the muscle layer just below the endometrium and grow toward the uterine cavity. These can form a stalk, or peduncle, and grow into the uterine space, called an intracavitary fibroid.
• Intramural fibroids grow inside the uterine wall, or myometrium. These tumors are also called interstitial fibroids, meaning that they grow within the wall itself.
• Subserous fibroids grow outward from the uterine wall toward the abdominal cavity. But they originate underneath the mucosal (peritoneal) surface, which is why they’re also called subperitoneal fibroids.

ICD-10 provides the following diagnosis codes to describe uterine fibroids:

• D25.0 — Submucous leiomyoma of uterus
• D25.1 — Intramural leiomyoma of uterus (or Interstitial leiomyoma of uterus)
• D25.2 — Subserosal leiomyoma of uterus (or Subperitoneal leiomyoma of uterus)
• D25.9 — Leiomyoma of uterus, unspecified.

For this case, you should assign D25.2 for the cervical fibroids, and D25.0 for the fibroid from the fundus.