Pathology/Lab Coding Alert

Question: How should we code this case: The pathologist identified a mucinous cystadenoma with a frozen section examination, then received an en-bloc spleen and distal pancreas for examination. The pathology report reads as:
 
Resection, pancreatic mass -- microcystic adenoma, margins clear, no malignant changes identified
Spleen -- mildly congested, free of tumor
Four lymph nodes -- negative for tumor.

New York Subscriber

Answer: Report the frozen section examination as 88331 (Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen). Also, you should report the permanent section examination of this pancreas biopsy specimen using 88307 (Level V - surgical pathology, gross and microscopic examination, pancreas, biopsy). 

Although the pathologist received the spleen and distal pancreas together, they represent two separate specimens, according to CPT definitions. Also, the pathologist separately examined and diagnosed the spleen and pancreas, as indicated in the pathology report. You should report the partial pancreas resection as 88309 (Level VI - surgical pathology, gross and microscopic examination, pancreas, total/subtotal resection) and the spleen as 88305 (Level IV - surgical pathology, gross and microscopic examination, spleen).

You should also report the lymph node examination separate from the pancreas and spleen. CPT does not bundle lymph nodes with pancreas or spleen, although it does bundle lymph nodes with some surgical pathology specimens. And since the surgeon does not typically resect lymph nodes attached to these organs, coding standards allow you to report the lymph nodes separately. Use code 88307 (Level V - surgical pathology, gross and microscopic examination, lymph nodes, regional resection).

-- Reader Questions were prepared with the assistance of R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.