Pathology/Lab Coding Alert

Question: We’re trying to code a pathology report with the following information:

Specimen: Ascending colon polyp x 2

Diagnosis: Hyperplastic polyps

Microscopic: Sections demonstrate polypoid colonic mucosa with hyperplastic glands containing a serrated luminal contour, which is most pronounced in the upper portions of the crypts. There is no adenomatous change identified.

Can we bill for two polyp specimens?

Codify Subscriber

Answer: You should not bill for two separate polyp specimens, even though the pathologist received and examined two polyps. 

Here’s why: The reason you should report only one unit of service is that the polyps are not “submitted for individual and separate attention,” which is the CPT® definition of a separate surgical pathology specimen. Based on the specimen description in the pathology report, it appears that the surgeon did not individually and separately identify the polyps. The surgeon would need to distinguish the two polyps in some way, such as submitting them in separate containers, or tagging (such as ink or suture) one polyp and describing the two polyps in a way that differentiates them, such as location or orientation.

Do this: You should code this case as 88305 (Level IV - Surgical pathology, gross and microscopic examination,… Polyp, colorectal…). 

Opportunity: Because the code definition states singular “polyp,” you could bill two units of 88305 for two colorectal polyps if the surgeon separately submits and identifies the polyps, and the pathologist individually diagnoses the polyps