Pathology/Lab Coding Alert

Question: Our pathologist received a breast lumpectomy specimen, and a single axillary lymph node in a separate container. He examined and diagnosed each, but I’m wondering if we should bundle the specimens for an 88309?

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Answer:  No, you should not self-bundle the specimens to report 88309 (Level VI - Surgical pathology, gross and microscopic examination, Breast, mastectomy - with regional lymph nodes). 

You indicate that the pathologist received and diagnosed two distinct specimens. That’s how you should code the case. The correct coding is as follows:

• 88307 — Level V - Surgical pathology, gross and microscopic examination, Breast, mastectomy - partial/simple

• 88305 — Level IV - Surgical pathology, gross and microscopic examination, Lymph node, biopsy

Watch for sentinel node: Always consider whether the pathology report documentation of a single lymph node describes a simple lymph node biopsy, or a more complicated sentinel lymph node exam. If the pathology report indicates that the exam is for a sentinel node, which is an “indicator” first node that drains to a lymph node basin, you’ll see documentation of additional work such as serial sectioning and staining do assess micrometastases in the lymph node. If the pathologist documents processing the specimen as a sentinel node, you should report 88307 (…Sentinel lymph node) instead of 88305.