Pathology/Lab Coding Alert

Question: If a surgeon performs a radical prosta-tectomy and separately submits the ampulla of vas deferens, can the pathologist report the tissue examination as two different specimens?

Tennessee Subscriber

Answer: If the tissues are submitted for separate examination and diagnosis, you should individually report the surgical pathology examination for each specimen. Report the radical prostatectomy as 88309 (Level VI Surgical pathology, gross and microscopic examination, prostate, radical resection) and the vas deferens as 88304 (Level III vas deferens, other than sterilization).

To code this way, however, you should have documentation that the surgeon requested individual examinations. If the surgeon submits an incidental, attached section of vas deferens without separate identification, do not report it as a separate specimen.

Although CPT bundles some tissues in resection procedures, such as fallopian tubes with ovaries, and ovaries and tubes with uterus, it does not bundle the vas deferens with a radical prostatectomy.