Pathology/Lab Coding Alert

Question: We frequently receive cervix cone biopsies. The inner and outer cone are in separate containers. How should they be coded?

Harriet William Drake, MD
Highland, Ill.

Answer: Regarding surgical pathology codes, CPT states that the unit of service for codes 88300 through 88309 is the specimen. CPT further defines a specimen as tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis. The important issue for coding this correctly is understanding whether there are one or two specimens. The number of containers does not affect how the case is coded.

The winter 1991 issue of CPT Assistant states, When material received for pathologic examination comprises multiple specimens, each specimen is a single unit of service and is to be reported using a single CPT code.

A cone is an inverted circular slice of tissue that is resected for pathologic study. If these two slices have been submitted for separate, individual evaluation and diagnosis as indicated by the ordering physician, then they should be coded separately. CPT lists a cervical conization as 88307; therefore, if you have received two separate cervical conization specimens, 88307 should be submitted twice. Remember, the fact that the tissue is submitted in separate containers is not relevant to determining whether they represent different specimens.