Pathology/Lab Coding Alert

Question: The pathologist examined a resection from a patient's left forearm that the surgeon identified as a "soft tissue mass." The pathologist's final diagnosis was "lipoma." Should I report 88305 or 88307 for this soft-tissue mass exam?

Maryland Subscriber

Answer: You should not report either 88305 (Level IV - Surgical pathology, gross and microscopic examination ... Soft tissue, other than tumor/mass/lipoma/debridement...) or 88307 (Level V - Surgical pathology, gross and microscopic examination ... Soft tissue mass (except lipoma) - biopsy/simple excision ...) for this case.

The correct code for the procedure you describe is 88304 (Level III - Surgical pathology, gross and microscopic examination ... Soft tissue, lipoma ...).

Here's why: You'll notice that both the 88305 and 88307 code descriptors exclude lipoma. For surgical pathology exams such as this one, you should always use the pathologist's final diagnosis to determine the appropriate code level. Even though the surgeon identified the specimen as a "soft tissue mass," the pathology report tells you that the actual diagnosis is "lipoma." That leads you to the appropriate 88304 code for this specimen exam.