Pathology/Lab Coding Alert

Question: The pathologist received a liver wedge biopsy specimen along with a lymph node in a separate container. How should we code this case?

New Mexico Subscriber

Answer: You should report the liver wedge biopsy using 88307 (Level V - Surgical pathology, gross and microscopic examination … Liver, biopsy - needle/wedge …). You should additionally report the lymph node pathology exam as 88305 (Level IV - Surgical pathology, gross and microscopic examination … lymph node, biopsy …).

Caution: Lymph nodes are bundled with certain anatomic pathology tissue specimens, so you need to determine if you can separately bill the lymph node biopsy in this case. For instance, CPT^® specifically lists lymph nodes as part of certain specimens, such as a breast resection, meaning that even a separate container doesn’t warrant unbundling the lymph node(s). Although partial resection or wedge biopsy liver specimens don’t list the inclusion of lymph nodes, coding convention indicates that you should not separately bill attached “incidental” lymph node(s) in liver cases.

Key: Because you have documentation that the surgeon separately identified and submitted a lymph node, and the pathologist separately examined and diagnosed the node, you may report 88305 (Level IV - Surgical pathology, gross and microscopic examination … lymph node, biopsy …) in this case, in addition to the 88307 for the liver biopsy.

Sentinel: You don’t indicate that the surgeon requested a sentinel lymph node exam for the specimen. If the surgeon had identified this as a sentinel node and the pathologist had performed the very in-depth exam required for a sentinel node, then you would bill the node exam as 88307 (… Sentinel lymph node …)