Pathology/Lab Coding Alert

Question: A patient had a partial mastectomy with cancer findings, including margins that were not clear. When the pathologist examines the breast re-excision specimen, including margin evaluation, what CPT code should we report? Does the code depend on whether the pathologist finds remaining malignancy?

Texas Subscriber

Answer: The CPT code for breast excisions does not depend on the diagnosis. For that reason, you will select the same code whether or not the pathologist finds any remaining malignancy in the re-excision specimen.

CPT describes several breast specimens in the surgical pathology section, and you should choose the proper code based on which definition most closely matches your specimen:

- 88305 -- Level IV, Surgical pathology, gross and microscopic examination; Breast, reduction mammoplastyBreast, biopsy, not requiring microscopic evaluation of surgical margins

- 88307 -- Level V, Surgical pathology, gross and microscopic examinationBreast, mastectomy -- partial/simpleBreast, excision of lesion, requiring microscopic evaluation of surgical margins

- 88309 -- Level VI, Surgical pathology, gross and microscopic examination Breast, mastectomy -- with regional lymph nodes.

Because you stated that the pathologist's examination of the re-excision specimen involves margin evaluation, you should report this specimen as 88307. The pathologist must document the margin examination to justify this code.