Pathology/Lab Coding Alert

Question: On a radical nephrectomy specimen, can an additional CPT 88307 be charged if the specimen includes the adrenal gland?

Michael Bailey, MD
Corpus Christi Medical Center, Corpus Christi, Texas

Answer: The charge for the radical nephrectomy would be CPT 88307 (surgery pathology, gross and microscopic examination; kidney, partial/total nephrectomy). This is another example that demonstrates the need for good documentation and direction on the part of the surgeon. You state that the specimen includes the adrenal gland, which implies that it is incidental. Unless there is specific direction to the pathologist to examine a separate adrenal resection, it should not be coded as a separate 88307. If the adrenal gland was removed incidentally to the nephrectomy, it must be examined and should be charged a code appropriate for the work involved rather than an 88307.