Pathology/Lab Coding Alert

Question: Our pathologist assessed a large skin specimen from the left side of the face that he diagnosed as an infundibular cyst. Is 88305 the correct code for this procedure?

Louisiana Subscriber

Answer:  No, what you’ve suggested is not the correct code for a large infundibular cyst from the left side of the face.

The anatomic origin of a skin specimen is not relevant to procedure code selection for a pathologist’s specimen examination and diagnosis. Nor is specimen size pertinent to your code choice.

Do this: Instead, you should choose the appropriate CPT^® code for any skin specimen exam based on the following possibilities:

• 88302 — Level II - Surgical pathology, gross and microscopic examination, Skin, plastic repair
• 88304 — Level III - Surgical pathology, gross and microscopic examination, Skin - cyst/tag/debridement
• 88305 — Level IV - Surgical pathology, gross and microscopic examination, Skin, other than cyst/tag/debridement/plastic repair.

In the context of these three skin code choices, you can see that you should report a cyst as 88304.

Don’t let the name fool you: You might also see an infundibular cyst called an epidermoid cyst, epidermal cyst, epidermal inclusion cyst, or keratin cyst. Regardless of the nomenclature, size, or location, you should report this type of specimen as 88304.