Pathology/Lab Coding Alert

Question: Our pathologist performed a touch preparation and frozen section on a bisected lymph node received during surgery and reported benign findings to the surgeon while the patient was still in the operating room. The pathologist later evaluated lymph node slides and reported a final diagnosis. How should we code?

California Subscriber

Answer: Based on your description of the intraoperative consult, you can report only the frozen section (88331, Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen) for the consultation. You should not additionally code the touch prep in this scenario. For the final lymph node diagnosis, use 88305 (Level IV, Surgical pathology, gross and microscopic examination, lymph node, biopsy).

Here's why: You can only report intraoperative frozen sections and touch preps for the same specimen if the pathologist documents that they're performed on separate sites. In other words, the procedures should provide different diagnostic information, such as specimen histology from the frozen section and margin evaluation from a touch prep at a different site on the specimen.

If the pathologist's documentation supports separate sites for the frozen section and touch preps, you could code the intraoperative consult as 88331 and +88334 (... cytologic examination [e.g., touch prep, squash prep], each additional site [list separately in addition to code for primary procedure]).