Pathology/Lab Coding Alert

Question: Our pathologist examined an eye enucleation specimen with a small piece of attached, fibrous tendon for a choroidal melanoma case. How should we code the pathology examination and diagnosis?

Massachusetts Subscriber

Answer: The appropriate code for the pathology exam is 88307 (Level V - Surgical pathology, gross and microscopic examination … Eye, enucleation …). You should report the diagnosis as C69.3- (Malignant neoplasm of choroid), with the fifth character 0, 1, or 2 for unspecified, right, or left eye, respectively.

An eye enucleation procedure involves removing the eyeball, leaving the eye muscles, tendons, and other contents of the eye’s orbit intact. In this way, the patient can be fitted with a prosthetic eye that can move and appear similar to the existing eye, but vision is not restored.

If the enucleated eye specimen has a small piece of attached tissue that is not separately submitted for examination and diagnosis, such as tendon, you should not report an additional surgical pathology code such as 88304 (Level III - Surgical pathology, gross and microscopic examination … Tendon/tendon sheath…).