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 [...]