Pathology/Lab Coding Alert

Question: How should we report the pathologist's examination of a humeral head submitted from a fracture? CPT Codes does not list humeral head, so should we consider it a "bone fragment"?

Arkansas Subscriber

Answer: Although CPT 2002 lists about 175 individual surgical pathology specimens under codes 88300-88309, it does not encompass every conceivable tissue that a pathologist may receive. When CPT does not list a particular surgical pathology specimen, it instructs coders that "any unlisted specimen should be assigned to the code which most closely reflects the physician work involved when compared to other specimens assigned to that code."

In this case, pathologists suggest that the listed specimen that most closely reflects the physician work involved in a humeral head examination is the femoral head. If your pathologist considers the work involved similar to a femoral head examination, code the exam to the same level of service (88305, Level IV Surgical pathology, gross and microscopic examination, femoral head, fracture) rather than as a bone fragment (88304, Level III bone fragment[s], other than pathologic fracture).