Pathology/Lab Coding Alert

Question: The pathologist received three pieces of prostate tissue in a single container. The op report stated that the procedure was transurethral resection of prostate. Should we bill this as a partial prostate resection?

Tennessee Subscriber

Answer: No, despite the use of the term “resection” in both the op report and the code definition, you should not report this case as a partial prostate resection pathology exam using 88307 (Level V - Surgical pathology, gross and microscopic examination … Prostate, except radical resection…).

Instead, you should bill the pathology exam of the specimen from a transurethral resection of prostate (TURP) procedure as 88305 (Level IV - Surgical pathology, gross and microscopic examination … Prostate, TUR …).

Units: During a TURP procedure, the surgeon typically uses a cystoscope with a cutting tool to excise bits of tissue and cauterize the excision site, resulting in multiple small tissue pieces submitted to pathology. You should report just one unit of 88305 for the pathologist’s exam of the multiple pieces.