Pathology/Lab Coding Alert

Question: A case involved the pathologist performing microscopic exam of a spontaneous abortion specimen at 23 weeks gestation. Should we bill this as 88305, and O02.1?

Florida Subscriber

Answer: No, those may not be the best codes for the case. You need to be sure the pathology report documents gestational age, and also the specific work involved in examining the specimen.

The diagnosis code O02.1 (Missed abortion) might seem correct, but ICD-10-CM goes on to describe the code as “Early fetal death, before completion of 20 weeks of gestation,” which is not accurate in the case you describe. Also, code O02.1 applies to record of the maternity patient of childbearing age (12-55).

The better choice for this case is P95 (Stillbirth), which includes fetal death of unspecified cause. Codes O02.1 and P95 are mutually exclusive, with each code appearing under an “Excludes 1” note for the other code.

You must get the diagnosis code right before you can choose the appropriate procedure code for this case. You have the following three code choices for this specimen:

• 88304 (Level III - Surgical pathology, gross and microscopic examination … Abortion, induced …)
• 88305 (Level IV - Surgical pathology, gross and microscopic examination … Abortion - spontaneous/missed)
• 88309 (Level VI - Surgical pathology, gross and microscopic examination … Fetus, with dissection …).

Assuming that the pathology report documents 23 week gestational age, and documents extensive dissection and microscopic exam of the fetus, the most accurate coding for this case would be P95 and 88309.