Pathology/Lab Coding Alert

Question: For a 59-year-old patient with a right ovarian mass, the surgeon submitted the uterus, tubes and ovaries in a single container. The pathologist assigned the diagnosis of cervicitis of the uterus and benign Brenner tumor of the right ovary. How should we code the pathologist's service?

Georgia Subscriber

Answer: Report the physician's examination of the neoplastic ovary as 88307 (Level V - surgical pathology, gross and microscopic examination, ovary with or without tube, neoplastic). For the uterus examination, report a second unit of 88307 (... uterus, with or without tubes and ovaries, other than neoplastic/prolapse).

Although CPT bundles incidental tubes and ovaries with the uterus, it also lists the ovary as a separate specimen. In your example, the neoplastic ovary is one specimen, and the non-neoplastic uterus is another.

The College of American Pathologists states that "when an ovary is removed because of a neoplasm and the uterus is also resected, the ovary is the primary specimen. Examination of the uterus is not included in the descriptor for evaluation of the ovarian neoplasm. Therefore, the separate evaluation of the uterus is coded based on the work involved (88307 for non-neoplasm or leiomyoma(s) or 88309 for neoplasm)" [July 1999 CAP Today].