Pathology/Lab Coding Alert

Question: The surgeon submitted a right oophorectomy specimen in one container with two separate containers for a pelvic lymph node biopsy and a para-aortic lymph node biopsy. The surgeon indicated the patient was at high risk for ovarian cancer based on elevated CA-125 and HE4 findings. The pathologist diagnosed invasive epithelial ovarian cancer with the pelvic node positive for epithelial carcinoma and the para-aortic lymph node negative for metastasis. How should we code this?

Illinois Subscriber

Answer: Because the surgeon separately submits a right ovary specimen and two distinct lymph nodes from separate regions, you should report this case as pathology exams of three separate specimens, as follows:

• 88307 (Level V - Surgical pathology, gross and microscopic examination … Ovary with or without tube, neoplastic …)
• Two units of 88305 (Level IV - Surgical pathology, gross and microscopic examination… Lymph node, biopsy…), one for each distinct lymph node.

Diagnosis: The primary diagnosis in this case is C56.1 (Malignant neoplasm of right ovary). ICD-10-CM states that for this diagnosis, you should “use additional code to identify any functional activity.” Because the surgeon reported elevated cancer antigen 125 (CA-125) and human epididymis protein 4 (HE4), you should additionally report R97.1 (Elevated cancer antigen 125 [CA 125]) and R97.8 (Other abnormal tumor markers) for the HE4 finding.

Pitfall: If you don’t document the diagnosis of malignant ovarian cancer, you cannot support billing 88307 for the ovary exam. Without a neoplastic diagnosis, you would bill the ovary exam as 88305 (… Ovary, with or without tube, non-neoplastic …). Failing to code this correctly could cost you $216.03. That’s because the 2024 Medicare Physician Fee Schedule pays $71.57 for 88305, and $287.60 for 88307 (national facility amount, conversion factor 33.2875).