Pathology/Lab Coding Alert

Question: Our pathologist received a uterus/tubes/ovaries specimen in which he diagnosed uterine leiomyoma and a Brenner tumor in one of the ovaries. I think that the findings mean we should report 88309 because of the neoplasm, even if benign. But the pathologist says we should stick with 88307. Who is correct? 

Colorado Subscriber

Answer: Neither a single unit of 88307 (Level V - Surgical pathology, gross and microscopic examination, Uterus, with or without tubes and ovaries, other than neoplastic/prolapse) or 88309 (Level VI - Surgical pathology, gross and microscopic examination, Uterus, with or without tubes and ovaries, neoplastic) is correct for this case. 

Your pathologist is correct that you should not charge a uterine leiomyoma as 88309, even though it is a benign neoplasm. That’s one of the tricky exceptions-by-convention that was established years ago by the College of American Pathologists (CAP) — a uterus with fibroids (leiomyoma) earns 88307.

However, you are correct that you should account for the Brenner tumor in your coding. You shouldn’t do it by upcoding the specimen to 88309, however.

Unbundle: Although the listed uterus specimens include incidental tubes and ovaries, you can “unbundle” this specimen if the pathologist finds a distinct pathology that requires individual attention, examination, and diagnosis in a tube or ovary. In this case, the ovary with the Brenner tumor earns an additional unit of 88307 (…Ovary with or without tube, neoplastic).

Final answer: Code this case as 88307 x 2.