Pathology/Lab Coding Alert

Question: How should we code the following case? Pathologist receives A) biopsy of right cheek lining and B) biopsy of palate. The frozen section diagnosis for A) is -squamous cell carcinoma- and for B) is -no evidence of malignancy.- 


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Answer: This case involves two separate specimens. That means you should report the two frozen section blocks -- one for the cheek lining and one for the palate -- as 88331 x 2 (Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen).

Notice: The number of frozen section blocks does not dictate your code selection. If the pathologist had performed frozen sections on two blocks from the same specimen, you would report 88331 and 88332 (- each additional tissue block with frozen section[s]) rather than 88331 x 2.

You should also report the pathologist's surgical pathology examination of the tissue. Again, because the case involves two separately identified specimens, you should bill 88305 x 2 (Level IV -- Surgical pathology, gross and microscopic examination, gingiva/oral mucosa, biopsy). 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.