Pathology/Lab Coding Alert

Question: We received three numbered containers. The contents of #1 was identified as left tonsil, #2 as the right tonsil, and #3 as adenoids. If each is separately diagnosed, what is the proper CPT pathology code?

Jeff Everts
Kalamazoo, Mich.

Answer: The tissue you have described is the whole tonsil, excised for some condition such as hyperplasia or obstruction, rather than an incisional tonsil specimen removed for a biopsy for a condition such as squamous cell carcinoma. That being the case, the proper code would be 88304 (Level III surgical pathology, gross and microscopic examination, tonsil and/or adenoids) rather than 88305 (tonsil, biopsy).

The question then becomes how many units of 88304 to report. In this case, each tonsil is separately identified and submitted for individual examination and pathologic diagnosis. Therefore they would represent two different specimens, and the work could be coded as two units of 88304. Despite the fact that the adenoids are separately identified, they should be bundled with one of the tonsils because CPT specifically states tonsil and/or adenoids.

Answered by R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services in Jonesboro, Ark.