Pathology/Lab Coding Alert
Breast-Reduction Examination
Question: How should we code the evaluation of breast tissue removed for breast-reduction surgery? We've been told by a plastic surgeon that others perform only a gross examination for cosmetic surgery, but we perform sections and micro as well. We've also been told that we should "discount" the service for cosmetic surgery. California Subscriber Reader Questions and You Be the Coder were prepared with the assistance of R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.
Answer: Reduction mammoplasty is a listed specimen in surgical pathology, so you should report it with the listed code. The correct code for examination of breast-reduction tissue is 88305 (Level IV Surgical pathology, gross and microscopic examination, breast, reduction mammoplasty). Performing gross and microscopic examination for this tissue is the standard of care; gross only for reduction mammoplasty is not. "Discounting" the pathology examination of this tissue is also inappropriate. You will notice that the reduction mammoplasty is already an 88305, similar to a breast biopsy not requiring margin evaluation, rather than an 88307 (Level V Surgical pathology, gross and microscopic examination), similar to a partial mastectomy.
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