Pathology/Lab Coding Alert

Question: A pathologist receives a skin specimen for diagnosis and frozen section evaluation of the margins. The pathologist reports to the surgeon that the posterior margin is incompletely excised. This would be coded 88305 for the surgical pathology exam of the skin, and 88331 for the frozen section. But what if the surgeon sends the pathologist an additional portion of the posterior margin, which the pathologist examines, and does another frozen section? Is this coded an additional 88305 and 88331, or 88332? Does coding depend on whether the margin is clear or still contains basal cell carcinoma?

North Carolina Subscriber

Answer: As you stated, the first skin specimen submitted for diagnosis and frozen section evaluation of the margins would be coded 88305 (level IV surgical pathology, gross and microscopic examination; skin, other than cyst/tag/debridement/plastic repair) and 88331 (pathology consultation during surgery with frozen section[s], single specimen).

If a different portion of the margin is later separately identified and submitted to the pathologist with a request for diagnosis and frozen section evaluation of the margins, then it constitutes another specimen. As such, the work involved should be coded an additional 88305 for the pathological examination of the skin specimen and 88331 for the consultation during surgery and frozen section evaluation. Code 88332 would be reported only if more than one tissue block is required on the same specimen during this second consultation. The use of modifier -59 (distinct procedural service) would be appropriate in this example. This would help explain that the specimens are different from one another.

The coding would be 88305, 88305-59, 88331,
88331-59. Be sure that the documentation supports the evaluation of all specimens.

The coding for this service would not depend on whether the margin is clear or still contains basal cell carcinoma. For the procedures involving these specimens, the coding depends on the work performed, not the outcome of the evaluation or final diagnosis.