Pathology/Lab Coding Alert

Question: How should I code a pathology report that lists frozen section exam from a breast lesion excision with three blocks, each involving multiple slides?


Maryland Subscriber

Answer: Because the frozen sections involve a single specimen, you should report the service as follows:

For the first tissue block, list 88331 (Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen).

For the next two tissue blocks, list 88332 x 2 (Pathology consultation during surgery; each additional tissue block with frozen section[s]).

If the pathologist examined three frozen section blocks from three separate specimens, such as three breast biopsies from three distinct locations, you would code the case differently. In that case, you would report 88331 x 3.

The general principal is to use 88331 for the first block from each distinct specimen, and 88332 for any additional blocks from the same specimen.