Pathology/Lab Coding Alert

Question: The pathologist received contents from a colonoscopy procedure in one container. The surgeon had noted “polyp” and “internal hemorrhoid, but had not marked to distinguish the tissue. The pathologist examined the tissue and identified two specimens, an adenomatous polyp and hemorrhoids. How should we code the case?

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Answer: Despite the fact that the surgeon submitted the tissue from the colonoscopy in one container, you should code the two distinct specimens based on the pathologist’s work and documentation.

Report the polyp exam as 88305 (Level IV - Surgical pathology, gross and microscopic examination … Polyp, colorectal …). The appropriate diagnosis code for adenomatous polyp is D12.6 (Benign neoplasm of colon, unspecified).

For the pathology exam of the hemorrhoids, list 88304 (Level III - Surgical pathology, gross and microscopic examination … Hemorrhoids …). The appropriate diagnosis code is 455.0 (Internal hemorrhoids without complication). Neither the surgeon nor the pathologist documented a complication that would require a different fourth character, such as bleeding, prolapse, or ulceration.