Pathology/Lab Coding Alert

Question: We received a mastectomy specimen based on a prior cancerous biopsy but find no residual tumor. How should we code the mastectomy (procedure and diagnosis)?

Kansas Subscriber

Answer: The final diagnosis for a mastectomy specimen doesn't change your procedure coding. You don't mention lymph nodes, so you should report the pathologist's mastectomy examination as 88307 (Level V --Surgical pathology, gross and microscopic examination, breast, mastectomy -- partial/ simple), regardless of the final diagnosis.

Diagnosis coding rules require you to report the most specific diagnosis available at the time. Here's how to do that:

1.If you have the pathologist's report and it includes a definitive diagnosis, you should use that diagnosis.

2.If the pathologist hasn't reached a definitive diagnosis, you should report the signs, symptoms, or conditions that prompted the ordering physician to request the service.

3.If the pathology report indicates no residual tumor and doesn't describe any pathology that's reportable to an ICD-9 code, you should revert to the ordering diagnosis. ICD-9 does not provide a code for "normal tissue," so you should list the condition that prompted the mastectomy. In other words, you should report the initial biopsy cancer diagnosis.

-- 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.