Pathology/Lab Coding Alert

Question: Our pathologist examines a breast excision and diagnoses “lobular carcinoma in situ (LCIS), margins clear.” What codes should I report for the case?

Michigan Subscriber

Answer: The proper procedure code is 88307 (Level V Surgical pathology, gross and microscopic examination…breast, excision of lesion, requiring microscopic evaluation of surgical margins…).

Your pathologist must document the margin exam for you to use this code. The diagnosis statement indicating “margins clear,” can serve as documentation of the margin exam. Without adequate documentation, you would need to report 88305 (Level IV Surgical pathology, gross and microscopic examination…breast, biopsy, not requiring microscopic evaluation of surgical margins…) instead.

Regarding the diagnosis code, you should assign the appropriate code from the following choices:

• D05.00 — Lobular carcinoma in situ of unspecified breast
• D05.01 — ... right breast
• D05.02 — ... left breast.