Pathology/Lab Coding Alert

Question: When the pathology report identifies a specimen as "sinus contents" and has a gross description that includes mucosa, bony fragments and sinus tissue, how should I code the case?

Tennessee Subscriber

Answer: CPT provides two codes for nasal sinus: 88304 (Level III -- Surgical pathology, gross and microscopic examination, polyps, inflammatory -quot; nasal/sinusoidal) and 88305 (Level IV -- Surgical pathology, gross and microscopic examination, sinus, paranasal biopsy). Although neither code uses the term "sinus contents," 88305 more closely fits the specimen you describe.

Sinus specimens can be tricky for coders because pathologists often use terms that you won't find in the CPT book. That means you should assign the code as you would for an unlisted specimen -- based on the code that "most closely reflects the physician work involved when compared to other specimens."

You can use the following list as a guide to common terms you might encounter and which codes best describe the level of work involved with those specimens:

- 88304 -- inflammatory nasal polyps, turbinates

- 88305 -- sinus contents, sinus stripping, sinus mucosal stripping (all of these terms describe a specimen that may contain fragments of tissue, mucosa, bone and/or cartilage), sinus biopsy.

Watch for decalcification: When you-re dealing with a specimen that might include bony tissue, look for the pathology report to mention decalcification. If you see that, you should list +88311 (Decalcification procedure [list separately in addition to code for surgical pathology examination]) in addition to 88304 or 88305.

Don't miss multiple units: If the pathology report identifies separate specimens, such as left and right sinus contents, make sure you code two units of service (such as 88305 x 2).