Pathology/Lab Coding Alert

Question: When the pathologist receives five nevi in two containers, how should we report the examination service? Should we consider all five nevi as one specimen, or should we code per nevus or per container?

Answer: The unit of service for surgical pathology examinations is the specimen. CPT defines the specimen as "tissue or tissues that is [are] submitted for individual and separate attention, requiring individual examination and pathologic diagnosis."

Based on your description, the surgeon doesn't appear to have distinguished among the submitted nevus in any way. Unless they are separately marked or identified with a surgical note (such as "two lesions in one container from left arm, lesions in additional container from left leg"), you should consider this one specimen. As such, you should report the service as 88305 (Level IV - Surgical pathology, gross and microscopic examination, skin, other than cyst/tag/debridement/plastic repair).