Pathology/Lab Coding Alert

Question: When choosing the proper surgical pathology level, what should we do if the final diagnosis disagrees with the specimen name? Based on the surgeon's identification, for example, the pathology report might list the specimen as -soft tissue mass, right side of neck.- But if the pathologist wrote the final diagnosis as -lipoma,- which should we use to assign the procedure code?


Florida Subscriber
Answer: You should use the most definitive information available -- in this case the pathologist's final diagnosis -- to assign the procedure code.

Report the pathologist's work as 88304 (Level III -- Surgical pathology, gross and microscopic examination; soft tissue, lipoma). You should not code this specimen as 88307 (Level V--Surgical pathology, gross and microscopic examination; soft tissue mass [except lipoma]--biopsy/simple excision). The code definition specifically excludes lipoma.

Exception: In the case of a tissue resection -for tumor- when the patient had a previous cancer diagnosis, you should report the higher code even if the pathologist does not diagnose neoplasm in the specimen.

For instance, if the surgeon performs a colon resection following a prior finding of a malignant polyp, you should use 88309 (Level VI -- Surgical pathology, gross and microscopic examination; colon, segmental resection for tumor) rather than 88307 (Level V -- Surgical pathology, gross and microscopic examination; colon, segmental resection, other than for tumor) regardless of the final diagnosis.