Pathology/Lab Coding Alert

Question: How should we code the pathologist's exam of left and right breast tissue from a reduction mammoplasty? Should we consider the specimen a biopsy or resection?

Minnesota Subscriber

Answer: The tissue is neither a breast biopsy nor a resection. CPT provides five listed breast specimens under surgical pathology codes 88305-88309 as follows:

• 88305 -- Level IV -- Surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins

• 88305 -- ... breast, reduction mammoplasty

• 88307 -- Level V -- Surgical pathology, gross and microscopic examination, breast, excision of lesion, requiring microscopic evaluation of surgical margins

• 88307 -- ... breast, mastectomy -- partial/simple

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

The correct code for reduction mammoplasty tissue is 88305 because that type of breast tissue is a listed specimen under 88305.

The pathologist almost always receives two separate specimens from the left and right breasts. Report the entire service as 88305 x 2. The key features that indicate this service are as follows:

• The specimen is normal breast tissue.

• The pathologist confirms healthy tissue. Do not use this code if the physician finds unexpected pathology that requires margin examination.

• The reason for the breast tissue removal is mammary hyperplasia.

• You would not expect to find lymph nodes submitted with reduction mammoplasty specimens.