Pathology/Lab Coding Alert

Question: Our pathologist received a specimen container labeled, "multiple colon biopsies," accompanied by an order to "rule out inflammatory bowel disease." The pathologist individually processed and diagnosed the three indistinguishable pieces of colon tissue as "benign colonic mucosa." How should we code the case?

Texas Subscriber

Answer: You should report a single unit of 88305 (Level IV - Surgical pathology, gross and microscopic examination, Colon, biopsy), even though the pathologist examined and diagnosed three biopsies.

Even though the pathologist individually processed and examined each biopsy, you can't distinguish the specimens to justify coding 88305 x 3.

CPT® direction: CPT® instruction states that the unit of service for 88300-88309 is the specimen. The instructions go on to define specimen as, "tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis. Two or more such specimens from the same patient (e.g., separately identified endoscopic biopsies, skin lesions) are each appropriately assigned an individual code reflective of its proper level of service."

"Separately identified": The key to this case is that the three colon biopsies are not separately identified, as required by  CPT® instruction to be assigned an individual code. Because the surgeon did not distinguish the biopsies in some way to specify the anatomic location of each biopsy, such as inking or suture, you have to lump them together for coding purposes.

Even though the pathologist individually examined and diagnosed each of the three biopsies, you cannot separate them for coding purposes because they are not individual identifiable according to CPT® definition.