Pathology/Lab Coding Alert

Answer: You should use the most definitive information available — in this case the pathologist’s final diagnosis — to assign the diagnosis code. That means you should report D17.0 (Benign lipomatous neoplasm of skin and subcutaneous tissue of head, face and neck) to describe the lipoma, not the non-specific code for a soft tissue mass of neck, R22.1 (Localized swelling, mass and lump, neck).

Procedure: This is a case that demonstrates an important principle about coding surgical pathology procedures — wait for the diagnosis before assigning the procedure code.

If you had assigned the procedure code prior to receiving the final diagnosis, you would appropriately select 88307 (Level V - Surgical pathology, gross and microscopic examination … soft tissue mass (except lipoma) -biopsy/simple excision …). But the correct code in this case is 88304 (Level III - Surgical pathology, gross and microscopic examination… Soft tissue, lipoma …).