Pathology/Lab Coding Alert

Question: A surgeon performs a tonsillectomy but submits the tonsils in separate containers and requests a biopsy of the right tonsil on suspicion of cancer. The adenoids come in yet another container. How should the pathologist code the case?

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Answer: Because the surgeon separately identifies the right and left tonsil, you should code them separately. For the left tonsil, which the pathologist examines as a tonsillectomy specimen, use 88304 (Level III -- Surgical pathology, gross and microscopic examination, tonsil and/or adenoids). You can see from the code definition that you must bundle the adenoids with this specimen, even if they are in a separate container.
 
For the right tonsil, which involves a tonsil biopsy, report 88305 (Level IV -- Surgical pathology, gross and microscopic examination, tonsil, biopsy).

Tip: Even if the surgeon did not request a biopsy on either tonsil, you could still report them separately if the surgeon identifies the right and left tonsil as distinct specimens. In that case, you would report 88304 x 2.