Pathology/Lab Coding Alert

Question: I’ve heard that the mass of a uterus is important for choosing the proper code, so how do I use that information in my code selection for the pathologist’s uterus exam?

Kentucky Subscriber

Answer: The mass of the uterus is not relevant to coding the pathologist’s exam of the organ. It is true that the mass impacts the surgeon’s code choice for removing the uterus (such as 58260, Vaginal hysterectomy, for uterus 250 g or less versus 58290, Vaginal hysterectomy, for uterus greater than 250 g).

That said, you do have several code choices for the pathologist’s exam of a uterus specimen, as follows:

• 88305 — Level IV - Surgical pathology, gross and microscopic examination … Uterus, with or without tubes and ovaries, for prolapse…
  
• 88307 — Level V - Surgical pathology, gross and microscopic examination … Uterus, with or without tubes and ovaries, other than neoplastic/prolapse
• 88309 — Level VI - Surgical pathology, gross and microscopic examination … Uterus, with or without tubes and ovaries, neoplastic….

You can see that the crucial information for your code choice is not the mass of the uterus, or whether the pathologist receives fallopian tubes and ovaries with the specimen, but the reason for the resection: prolapse (88305), neoplasm (88309), or some other reason (88307), such as uterine fibroids.