Pathology/Lab Coding Alert

Question: How should we code when a biopsy is submitted initially for frozen section or for fresh tissue consult, and is then followed by the definitive specimen? For example, a lymph node is submitted as a sentinel node, followed by a separately submitted axillary node dissection. Should this be coded 88305 for the sentinel node and an additional 88307 for the axillary node dissection? Or is it a single 88307? In similar situations, how should I code for a breast biopsy for frozen section followed by a mastectomy, and for a thyroid biopsy for frozen, followed by thyroidectomy?

Iowa Subscriber

Answer: Regarding, the sentinel lymph node followed by an axillary node resection, the examination of a sentinel node would be 88307 ( sentinel lymph node). This is based on the addition of sentinel lymph node to the specimen list for 88307 in CPT 2001. If the sentinel node was positive and was followed by the removal of axillary nodes, the pathologist would bill an additional 88307 ( lymph nodes, regional resection).

Your example of the breast biopsy for frozen section followed by a mastectomy would be coded as follows: The frozen section should be coded 88331 (pathology consultation during surgery; first tissue block, with frozen section[s], single specimen) and 88332 (... each additional tissue block with frozen section[s]) if additional blocks are performed. Assuming the specimen is not the excision of the entire lesion, the biopsy is coded 88305 (level IV surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins). Based on the results of these analyses, the surgeon may determine to perform a modified radical mastectomy. If so, the pathologists evaluation of this specimen would be reported as 88309 (level VI surgical pathology, gross and microscopic examination, breast, mastectomy - with regional lymph nodes).

Similarly, if a thyroid biopsy was used to provide a diagnosis, and was later followed by the thyroidectomy specimen, each service would be reported separately. Because thyroid biopsy is not a listed specimen, the pathologist would assign the proper surgical pathology code based on the level of work involved (possibly 88305). The thyroidectomy would be coded 88307 (level V surgical pathology, gross and microscopic examination, thyroid, total/lobe).