Pathology/Lab Coding Alert

Question: For a pathology exam of a uterus specimen in which the pathologist diagnosis “high grade hyperplasia,” should we report 88307? What is the proper diagnosis code?

Wisconsin Subscriber

Answer: No, you should not bill 88307 (Level V surgical pathology, gross and microscopic examination…uterus, with or without tubes and ovaries, other than neoplastic/prolapse) for your pathologist’s exam of a uterus with high-grade hyperplasia.

Unlike most surgical pathology services, the diagnosis impacts procedure coding for examination of the uterus. So the procedure code will be different depending on the type of dysplasia involved.

If the dysplasia found in the specimen is high-grade, the diagnosis is carcinoma in situ, which you should report with a code such as D06.9 (Carcinoma in situ of cervix, unspecified). The procedure code for a neoplastic uterus exam is 88309 (Level VI, surgical pathology, gross and microscopic examination…uterus, with or without tubes and ovaries, neoplastic…). Based on the significant dysplasia, the pathologist would have to examine this specimen more extensively, for example, requiring more sections and evaluation of margins. That is why neoplastic uterus is listed as 88309.

If the dysplasia is low-grade (N87.0, Cervical intraepithelial neoplasia I [CIN I]), the proper procedure code would be 88307. The evaluation of a non-neoplastic uterus is less extensive than for a neoplasm, thus CPT^® establishes this specimen at a lower level of service (88307).