Pathology/Lab Coding Alert

Question: We are concerned with pathology billing for a hysterectomy, with or without ovaries, which is done to exclude invasive carcinoma in a patient with known squamous carcinoma in situ of the cervix. The extensive extra sampling of the cervix is documented in both the gross and micro exams, and the other codes reflect the cancer diagnosis. How should we code this?

Michigan Subscriber

Answer: If the uterine specimen (with or without ovaries) is received with a diagnosis positive for in-situ carcinoma (any site), the surgical pathology code that most reflects the level of work is the 88309 (level VI, surgical pathology, gross and microscopic examination; uterus, with or without tubes and ovaries, neoplastic), since you are examining to determine the nature of a neoplasm. If there were no history of carcinoma, then the 88307 (level V, surgical pathology, gross and microscopic examination; uterus, with or without tubes and ovaries, other than neoplastic/prolapse) would be more appropriate.