Pathology/Lab Coding Alert

Question: We have recently been receiving mastectomy specimens consisting of a breast with attached lymph nodes for which the stated procedure on our surgical pathology form is simple mastectomy or simple mastectomy with axillary dissection. Should we use 88307 x 2 for simple mastectomy and axillary dissection, or does the presence of the attached lymph nodes make 88309 more appropriate?

What we often do in these cases is review the transcribed operative procedure note. We may find the procedure called a modified radical mastectomy with lymph node dissection, which seems to contradict the stated specimen on the surgical pathology form.

Nebraska Subscriber

Answer: The key to coding these specimens is determining whether the removed breast tissue was originally contiguous with the lymph nodes (whether they are separated when they are received). If the breast and lymph tissues were contiguous, the specimen is reported as surgical pathology 88309 (level VI surgical pathology, gross and microscopic examination, breast, mastectomy - with regional lymph nodes). This type of specimen may be described using several names, such as simple mastectomy with axillary dissection, or modified radical mastectomy. Regardless of the name, use 88309 for breast tissue with contiguous lymph nodes.

On the other hand, if the breast tissue specimen was not contiguous with the lymph basin, the two should be reported as separate specimens. In that case, the breast tissue is reported as surgical pathology 88307 (breast, excision of lesion, requiring microscopic evaluation of surgical margins) or (breast, mastectomy - partial/ simple). These types of breast specimens may be described as partial mastectomy, quadrantectomy or lumpectomy (not including simple mastectomy, which would be contiguous with the lymph nodes). The discontinuous breast tissue and lymph nodes require individual examination and pathologic diagnoses, often including evaluation of surgical margins. The lymph nodes are separately reported as surgical pathology 88307 (lymph nodes, regional resection).

In other words, if the medical record clearly indicates that the specimen is some form of partial mastectomy, with an unattached axillary lymph node resection submitted for separate evaluation and diagnosis, 88307 x 2 would be appropriate. This concurs with CPT Assistant, which states: If the node(s) are attached to the primary specimen, they would not be coded separately. However, if the node(s) are a separate specimen, they would be coded separately as 88307 (Fall 1993). Be careful to note that this does not refer to a single specimen that happens to be submitted in separate containers, but refers to tissues that represent separate specimens based on the CPT definition (tissue or tissues that is [are] submitted for individual and separate attention, requiring individual examination and pathologic diagnosis).

Based on your question, it sounds as if the problem involves documentation of the procedure, and perhaps the selection choices on the surgical pathology form you mentioned. Physician education regarding the code choices and the importance of completely and accurately identifying the surgical specimen(s) submitted for pathology examination could go a long way to alleviate the problem.

Answered by R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services, an independent pathology laboratory in Jonesboro, Ark.