Pathology/Lab Coding Alert

Answer: You should bill the polyp exams as four units of 88305 (Level IV - Surgical pathology, gross and microscopic examination … Polyp, colorectal …), plus one unit of 88302 (Level II - Surgical pathology, gross and microscopic examination …) for the fecal material exam.

The surgeon identified five polyps, and the lab prepared and the pathologist examined slides from all five specimens, so the pathologist must account for each specimen in the final report. But you should not bill for a polyp exam when it turns out that one of the specimens does not contain polyp tissue.

Instead, you should bill the specimen that turned out to be fecal material using an appropriate code, such as 88302, because the pathologist performed gross and microscopic evaluation that amounted to identifying the specimen. That level of work is similar to the work involved in listed specimens under 88302, such as newborn foreskin from a circumcision.

Remember: When the pathologist examines an “unlisted” specimen, you should assign the code “which most closely reflects the physician work involved when compared to other specimens assigned to that code,” according to CPT^® instruction.