Pathology/Lab Coding Alert

Question: The pathologist received a cervical biopsy from a patient with a pre-op diagnosis of human papillomavirus (HPV) and mild dysplasia. The pathology report for the biopsy states a diagnosis of koilocytosis. What are the proper diagnosis and procedure codes for this situation?

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Answer: The proper procedure code is 88305 (Level IV Surgical pathology, gross and microscopic examination, cervix, biopsy) regardless of the diagnosis. The pathologist noted koilocytosis, which describes cellular changes that appear as halos around the nuclei indicating HPV infection. Koilocytosis often appears with dysplasia and may be associated with HPV infection. The appropriate ICD-9 code for koilocytosis is 622.1 (Cervical atypism). If the pathologist also reports HPV infection, assign 079.4 (Human papillomavirus) as well.

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.; and Laurie Castillo, MA, CPC, CPC-H, CCS-P, member of the National Advisory Board of the American Academy of Professional Coders and vice president of ambulatory services, Health Revenue Assurance Associates in Chapel Hill, N.C.