Pathology/Lab Coding Alert

Question: A specimen is submitted as a lipoma of the cord. It is, but it is also a hernia sac. Should I bill for both? How is it coded?

Mississippi Subscriber

Answer: From your description, it appears that the hernia sac is incidental and not a separate specimen. You stated that the surgeon indicated the specimen for examination was lipoma of the cord.

In that case, bill 88304 (level III, surgical pathology, gross and microscopic examination; hernia sac, any location; soft tissue, lipoma). In general, you can bill for two services only if the tissues are submitted and identified by the surgeon as separate specimens. A suture, a mark or a surgical note might identify that they are submitted for individual, separate examination and pathologic diagnosis. Only then would the pathologist examine and report on each specimen, making a separate entry for each in the report.