Pathology/Lab Coding Alert

Question: The pathologist performs frozen sections and a surgical pathology exam of right fallopian tube and ovary, with findings of poorly differentiated papillary serous carcinoma of the ovary. The pathologist also examines the uterus, with a finding of metastatic poorly differentiated papillary serous carcinoma. How should we code this?

Utah Subscriber

Answer: You should report the frozen sections with 88331 (Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen). You did not specify multiple blocks, but if the pathologist examined frozen sections from more than one block from the ovary, report the second and subsequent blocks, each with 88332 ( each additional tissue block with frozen section[s]).

Without firm documentation to the contrary, don't unbundle tubes and ovaries from the uterus. Although your example hints that the ovary was submitted first and separately, without definitive documentation that the surgery was other than a hysterectomy, you should report the examination of the uterus, tube and ovary as 88309 (Level VI Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, neoplastic).

CPT bundles tubes and ovaries with uterus, so you can't report these as separate specimens unless the surgeon provides documentation that the ovary was the primary specimen with the uterus removed secondarily. For example, if the surgeon removes the ovary for a mass and intraopera-tively identifies the carcinoma, then removes the uterus for metastatic involvement, you may report the ovary and uterus as separate specimens. The ovary would be 88307 (Level V Surgical pathology, gross and microscopic examination, ovary with or without tube, neoplastic).