Pathology/Lab Coding Alert

Question: The surgeon submitted a hysterectomy in three separate containers identified as follows: A) right tube and ovary, B) uterus and cervix, C), left tube and ovary. The pathologist diagnosed A) as a serous cystadenoma, B) as a leiomyoma, and C) as an incidental tube and ovary. How should we code?

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Answer: You should report the service as two units of 88307 (Level V - Surgical pathology, gross and microscopic examination, ovary with or without tube, neoplastic). Based on the tissue submitted and the pathologist's diagnoses, here's the breakdown for your code selection:

A) Right ovary with tube, serous cystadenoma. Report 88307, because the ovary involves a primary ovarian cancer that demonstrates distinct pathology from the uterus specimen. Although you should typically bundle ovaries with a hysterectomy specimen, you can separately code an ovary when the pathologist documents distinct pathology.

B) Uterus and cervix, leiomyoma. Report 88307 (... uterus, with or without tubes and ovaries, other than neoplastic/prolapse) for uterus with fibroids. Because the left tube and ovary submitted in C is incidental and shows no distinct pathology, you should bundle these adnexa with the uterine specimen for coding purposes. Don't additionally report 88305 (Surgical pathology, gross and microscopic examination, ovary with or without tube, non-neoplastic) for the contents of container C.

Here's why: Because hysterectomy specimens often include incidental fallopian tubes and ovaries, CPT® bundles the adnexa with the uterus, based on the 88305 (... uterus, with or without tubes and ovaries, for prolapse), 88307 and 88309 (Level VI - Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, neoplastic) definitions.

But when the pathologist must separately examine tubes and ovaries because of distinct pathology, they're not incidental, and you should consider them a separate specimen for coding purposes.