Pathology/Lab Coding Alert

Question: Our pathologist received the following case in a single container: Gastrectomy consisting of stomach with 3 cm attached strip of omentum, attached spleen, and fatty tissue with 16 lymph nodes. The pathologist separately examines and diagnoses adenocarcinoma of the stomach with clear omental margin, spleen negative for tumor, no evidence of lymph metastasis. How should we code the case?

Minnesota Subscriber

Answer: Although the pathologist received all the tissue together in a single container identified only as a gastrectomy, you can separately charge for multiple specimens based on the fact that that the pathologist individually identified, examined, and diagnosed distinct tissues.

Choose stomach code first: CPT® provides two distinct codes for a partial or total stomach resection based on whether the specimen is "for tumor":

• 88307 -- Level V -- Surgical pathology, gross and microscopic examination, stomach--subtotal/total resection, other than for tumor
• 88309 -- Level VI -- Surgical pathology, gross and microscopic examination, stomach--subtotal/total resection for tumor.

You should report 88309 for this case since the pathologist diagnosed adenocarcinoma in the stomach. The omentum in this case is a strip of tissue that represents the surgical margin, so you should bundle that with the stomach resection code. Based on coding convention and the fact that the pathologist separately identifies, examines, and diagnoses other specimens, you can also code the following for this case:

• 88305 -- Level IV -- Surgical pathology, gross and microscopic examination, spleen
• 88307 -- Level V -- Surgical pathology, gross and microscopic examination, lymph nodes, regional resection.