Pathology/Lab Coding Alert

Question: At our hospital, we have a fairly common situation when a patient delivers a baby and has bilateral tubal ligation on the same day. The pathologist then examines these specimens: bilateral tubes and placenta. Why is the gross exam of the placenta always denied, and what can we do to get paid?


Georgia Subscriber

Answer: Many carriers and insurers have edits in place that bundle the surgical pathology gross exam (88300, Level I--Surgical pathology, gross examination only) with each of the surgical pathology gross and microscopic exams (88302-88309, Levels II-VI--Surgical pathology, gross and microscopic examination). Although the National Correct Coding Initiative (NCCI) does not bundle these codes, years ago, a Medicare "black-box" edit prohibited using these codes together, and many insurers still bundle 88300 with the other surgical pathology codes.

The reason for the edit is clear--each of the 88302-88309 levels includes a gross exam. But a problem arises when your pathologist performs a gross exam on one specimen and a gross and microscopic exam on a separate specimen. Then you have a legitimate charge for 88300 and another surgical pathology code, and you have to override the edit.

In the case you mention, the proper coding would be 88300 for the placenta gross exam and 88302 (... fallopian tube, sterilization) for the fallopian tubes if the surgeon submits them as a single specimen.

Although the code definition is singular, you should report 88302 x 2 only if the surgeon separately identifies the right and left tubes and the pathologist provides a separate diagnosis for each.

If your payer bundles 88300 with 88302, you'll have to follow the payer's instructions for reporting both codes together when they refer to separate specimens.

The most common method is to use modifier 59 (Distinct procedural service) to indicate that the 88300 for the placenta and the 88302 for the fallopian tube(s) are separate services.