Pathology/Lab Coding Alert

Question: If a specimen is referred to as a lumpec-tomy, should the tissue be interpreted as a biopsy (88305) or a partial mastectomy (88307)? We frequently receive large lumpectomies or needle localization biopsies of breast tissue removed for microcalcifications. To ensure that the microcalcifications are visualized microscopically, we sometimes submit the whole thing in 20 cassettes. Only after we look at the 20 slides can we determine that the microcalcifications are benign. If the surgeon labeled this a biopsy in the op report and it is found to be benign, do we use 88305?
              
Georgia Subscriber
 
Answer: The key difference between a breast tissue specimen reported as 88305 and one reported as 88307 is whether the specimen requires microscopic evaluation of surgical margins. A breast biopsy is reported using 88305 (Level IV Surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins). This is true of a needle localization biopsy or removal of a portion of a lesion by any other method, regardless of the specimen size.
 
The term lumpectomy indicates removal of the entire lesion, requiring evaluation of surgical margins, regardless of the size of the specimen. Evaluation of this type of breast tissue specimen is described with 88307 (Level V Surgical pathology, gross and microscopic examination, breast, excision of lesion, requiring microscopic evaluation of surgical margins; or breast, mastectomy - partial/simple). These types of breast specimens may be described as partial mastectomy, quadrantectomy or lumpectomy.
 
Whether the specimen is large and requires many slides for the evaluation of microcalcifications is not relevant to the coding. Specimens listed under the CPT surgical pathology codes must be reported as listed, whether or not the particular specimen requires an average amount of work. Just as pathologists would not downcode for a particularly small, easy specimen, they should not upcode for a particularly large, difficult specimen.
 
Nor is the final diagnosis of the specimen, whether neoplastic or benign, relevant to the code assignment for surgical examination of breast tissue. Report 88305 for breast tissue not requiring surgical evaluation of margins, such as biopsies, and 88307 for breast tissue such as partial mastectomies not containing lymph tissue and for specimens requiring margin evaluation such as lumpectomies, regardless of final diagnosis. For evaluation of a mastectomy including regional lymph nodes, report 88309 (Level VI Surgical pathology, gross and microscopic examination, breast, mastectomy with regional lymph nodes).
 
 
Answers to Reader Questions and You be the Coder were answered by Laurie A. Castillo, MA, CPC, CPC-H, CCS-P, president of Physician Coding and Compliance Consulting in Manassas, Va.; and R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services in Jonesboro, Ark.