Pathology/Lab Coding Alert

Question: We received an excision specimen labeled “left thumb mass.” The pathologist examined the tissue and reported that his findings were “consistent with follicular cyst.” Should we report 88307 for soft tissue mass or 88304 for cyst, even though the pathologist used the terminology “consistent with”?

Tennessee Subscriber

Answer: The best choice for this specimen exam is 88304 (Level III - Surgical pathology, gross and microscopic examination…, skin - cyst/tag/debridement…). 

You can usually report a pathologist’s statement of “consistent with” as a conclusive diagnosis, unless the pathology report indicates otherwise. You are correct that you should not report a diagnosis if it is not conclusive, for instance, if the pathologist used terminology such as “suspicious for,” “rule out,” or “probable.” 

In this case, the pathologist’s statement indicates that the specimen is skin, because follicular cysts arise in the dermis. That leads to the 88304 code choice.

Even if something in the pathology note leads you to believe that follicular cyst is not a firm diagnosis, you should not use 88307 (Level V - Surgical pathology, gross and microscopic examination…, Soft tissue mass [except lipoma]…) because this is a skin specimen, not a soft tissue specimen.