Pathology/Lab Coding Alert

Question: When the pathologist evaluates fallopian tubes removed for sterilization, what procedure codes should we use? Also, is V26.51 or V25.2 the correct diagnosis code?

Connecticut Subscriber

Answer: The correct ICD-9-CM code for sterilization is V25.2 (Sterilization), which includes "admission for interruption of fallopian tubes or vas deferens." ICD-9 lists the other code you mentioned, V26.51 (Tubal ligation status), for secondary diagnosis only. As a status and secondary diagnosis code, you should not list it as the primary reason for the procedure.
 
If the surgeon does not separately identify the products of sterilization (fallopian tubes), you should report the pathologist's examination as 88302 (Level II - Surgical pathology, gross and microscopic examination, fallopian tube, sterilization). But if the surgeon separately identifies right and left tubes from the sterilization for examination, the pathologist should list a diagnosis for each tube, and you should report 88302 x 2.
 
Although other surgical pathology codes list fallopian tube as a specimen, 88302 is the correct code for tubes removed for sterilization. The other fallopian tube codes are 88305 (Level IV - Surgical pathology, gross and microscopic examination, fallopian tube, biopsy), or (... fallopian tube, ectopic pregnancy). CPT also bundles fallopian tube with ovary when the ovary is the primary specimen (88305, ... ovary with or without tube, non-neoplastic) or 88307 (Level V - Surgical pathology, gross and microscopic examination, ovary with or without tube, neoplastic).