Pathology/Lab Coding Alert

Question: Our pathologist examined a “trigone of bladder biopsy” with findings of “benign urothelial submucosa and mucosa with cystitis and granulomatous inflammation, with no neoplasia evidence.” How should we code the case?

Kentucky Subscriber

Answer: The correct procedure code for the case is 88305 (Level IV - Surgical pathology, gross and microscopic examination,… urinary bladder, biopsy…). The correct diagnosis code is N30.30 (Trigonitis without hematuria), although if the documentation indicated blood in the urine, you would instead choose N30.31 (Trigonitis with hematuria).

The trigone of bladder is a region of the urinary bladder at the juncture of the internal urethral opening and the two ureteral orifices. The key to your code selection is based less on the fact that the specimen is the trigone of bladder than on the fact that the report documents that the specimen is a bladder biopsy.

Pathologists may also examine a trigone of bladder transuretheral resection (TUR) specimen or a partial bladder resection specimen involving the trigone region, which you would bill using different codes, as follows:

• 88307 --Level V - Surgical pathology, gross and microscopic examination…urinary bladder, TUR…
• 88309 -- Level VI - Surgical pathology, gross and microscopic examination, urinary bladder, partial/total resection.