Pathology/Lab Coding Alert

Question: What are the proper codes for the following?

1. Uterus with cervical dysplasia or history of dysplasia whether or not residual dysplasia is found in hysterectomy.

2. Multiple touch preps (intraoperative consultation) on a single specimen from different sites (margins), e.g., breast lumpectomy for history of carcinoma.

3. Skin removed for hidradenitis.

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Answer: 1. Unlike many services, the diagnosis impacts the procedure coding for examination of some surgical specimens such as uterus. So the procedure code will be different depending on the type of dysplasia involved.

If the dysplasia found in the specimen is high-grade, the diagnosis is carcinoma in situ (233.1), and the procedure would be reported as 88309 (level VI surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, neoplastic). Based on the significant dysplasia, the pathologist would have to examine this specimen more extensively, for example, requiring more sections and evaluation of margins. That is why neoplastic uterus is listed as 88309.

If the dysplasia is low-grade (622.1), the procedure would be reported as 88307 (level V surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, other than neoplastic/prolapse). The evaluation of a non-neoplastic uterus is less extensive than for a neoplasm, thus the specimen requires a lower level of service (88307).

If there is no residual dysplasia in the hysterectomy specimen, the procedure code would depend on the history of dysplasia. If the history involved high-grade dysplasia, report 88309; if low-grade, report 88307 because the extent of the examination of the hysterectomy specimen depends on the original diagnosis.

2. The intraoperative consultation involving touch preps (not frozen sections) should be reported as 88329 (pathology consultation during surgery). Assuming that each touch prep is separately labeled or identified, each should be reported as one unit of 88161 (cytopathology, smears, any other source; preparation, screening and interpretation). When touch preps are used to indicate if the margins of a lumpectomy are clear, each touch prep is usually individually identified so that the surgeon will know which margin (if any) contains residual abnormal cells. So if a pathologist is called to surgery for a consult on four touch preps for lumpectomy margins, the appropriate coding would be 88329 and 88161x4.

3. Pathologist evaluation of skin removed for hidradenitis (705.83) should be reported as 88305 (level IV surgical pathology, gross and microscopic examination, skin, other than cyst/tag/debridement/plastic repair).

Answered by R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services, an independent pathology laboratory in Jonesboro, Ark.