Pathology/Lab Coding Alert

Question: When our pathologist diagnoses uterine fibroid tumors, what ICD-9 code should we use?

Pennsylvania Subscriber

Answer: You should choose the diagnosis based on the fibroid's location:

• Submucous fibroids (218.0, Submucous leiomyoma of uterus) grow from the uterine wall toward the uterine cavity. They are also called intracavitary fibroids.

• Intramural fibroids (218.1, Intramural leiomyoma of uterus) grow within the uterine wall (myometrium). They are also called interstitial fibroids.

• Subserous fibroids (218.2, Subserous leiomyoma of uterus) grow outward from the uterine wall toward the abdominal cavity. They are also called subperitoneal fibroids.

• If the physician does not specify the uterine fibroid's location, assign 218.9 (Leiomyoma of uterus, unspecified) as the diagnosis.

CPT alert: You should code the pathology exam of uterus with leiomyomas as 88307 (Level V " Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, other than neoplastic/prolapse).

Although ICD-9 classifies leiomyoma as a benign neoplasm, a coding convention supported by the American Medical Association and the College of American Pathologists dictates that you code this condition as 88307, not 88309 (Level VI -- Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, neoplastic).

For myomectomy specimens -- fibroid tumors that the surgeon removes while leaving the uterus intact -- bill the pathology exam as 88305 (Level IV -- Surgical pathology, gross and microscopic examination, leiomyoma[s], uterine myomectomy -- without uterus).

-- Reader Questions and You Be the Coder were prepared with the assistance of R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.