Pathology/Lab Coding Alert

Question: We often receive urinary bladder specimens for which the stated procedure is something like transurethral resection (TUR) bladder tumor, but the specimen is called bladder biopsy. Should we use 88305 for biopsy or 88307 for TUR bladder?

If the specimen is not called anything more specific than just bladder, with the procedure TUR, we have been using 88307. These bladder specimens are often so small that we feel guilty using 88307.

Georgia Subscriber

Answer: You should code based on the specimen: Is it a biopsy or a tumor resection? For a bladder biopsy specimen, which is a small portion of a bladder tumor or suspicious area, use 88305 (level IV surgical pathology, gross and microscopic examination, urinary bladder, biopsy). For a bladder tumor resection, which would comprise the entire tumor and generally be a larger specimen, use 88307 ( urinary bladder, TUR). The R in TUR stands for resection, which, by definition, means removal or excision.

The confusion occurs because the term TUR is frequently used by the surgical staff to define a method of entry to retrieve the specimen. More specifically, TUR describes the method of entry and the specimen, which is a resection. Although a biopsy can be obtained by the same method of entry (transurethral), that procedure should be described as a TU biopsy, since the specimen is not a resection.

Just remember that the key to coding the specimens in question accurately is understanding whether it is a bladder biopsy or a bladder resection. Dont let the TUR procedure terminology mislead you. Use 88305 for the bladder biopsy, and 88307 for the bladder resection.

If the documentation you receive presents conflicting information about the specimen, you will need to clarify it with the surgeon. Educating the physicians about the codes, the potential conflict in terminology and the need for accurate documentation may also help.

Answered by R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services, an independent pathology laboratory in Jonesboro, Ark.