Pathology/Lab Coding Alert

Question: The op note states that the surgeon performed a herniorrhaphy and that the submitted specimen was an inguinal hernia sac. But the pathologist diagnosed the specimen as a spermatic cord lipoma. What are the diagnosis and procedure codes I should use?

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Answer: You should code based on the pathologist’s documentation, which means that the appropriate ICD-10-CM code is D17.6 (Benign lipomatous neoplasm of spermatic cord).

The appropriate procedure code for this exam is 88304 (Level III - Surgical pathology, gross and microscopic examination … Soft tissue, lipoma; Spermatocele …), because a spermatic cord lipoma is an equivalent specimen.

Better pay: Getting the diagnosis code right in this case makes a difference in the procedure code you choose to describe the pathologist’s work, and thus the pathologist’s pay. If the specimen was indeed a hernia sac, such as K40.90 (Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent), not a spermatic cord lipoma, you would have to bill the procedure accordingly. That would mean reporting 88302 (Level II - Surgical pathology, gross and microscopic examination … Hernia sac, any location…) instead of the higher-paying 88304.