Pathology/Lab Coding Alert

Question: The pathologist examined a “paranasal sinus osteoma” specimen. The pathology report states “submitted in two blocks following decalcification.” How should I code this case?

Illinois Subscriber

Answer: The correct codes are 88305 (Level IV Surgical pathology, gross and microscopic examination … bone exostosis…) and +88311 (Decalcification procedure [List separately in addition to code for surgical pathology examination]).

An osteoma is the same as an exostosis, which is a benign growth of bone over bone, often covered with cartilage. These commonly occur in the paranasal sinus, and may be removed to relieve blockage and relieve associated sinus infections.

When the pathologist indicates decalcification of a bony specimen, you should always capture the service with add-on code +88311.

Watch units: Remember that the unit of service for both the exostosis and the decalcification is the specimen, regardless of the number of blocks or slides. You should not bill more than one unit of 88305 or +88311 for this case.