Pathology/Lab Coding Alert

Question: I have a cancerous tonsil resection along with a radical neck procedure in a separate container. Is the tonsil an CPT 88309 , and the dissection an 88307, or is it all treated as a global 88309?

Byron Arndt
Medford, Ore.

Answer: The tonsil resection should be reported using 88309 (tongue/tonsil-resection for tumor). The terminology radical neck, however, describes a procedure, but does not define the actual tissue being evaluated by the pathologist.

A description of the specimen(s) received for the radical neck dissection must be documented to assign the appropriate codes. The tissue submitted from the neck dissection is considered a separate specimen only if it is submitted for individual and separate examination and pathologic diagnosis. The physician submitting the specimen should indicate this.

The coding for the tissue from the neck dissection depends on what tissue is involved. For instance, if the specimen includes the larynx and associated lymph nodes, an additional unit of 88309 would be appropriate (larynx, partial/total resection with regional lymph nodes).

Answered by Laurie A. Castillo, MA, CPC, CPC-H,
CCS-P, president and owner of Physician Coding & Compliance Consulting, in Virginia., and president, AAPC Northern Virginia Chapter.