Pathology/Lab Coding Alert

Question: Our pathologist received two distinctly identified anal condylomata and an anal biopsy from the lateral anal verge, as well as one from the proximal denate line for anal intraepithelial neoplasia evaluation. Should we code 88304 or 88305?

Minnesota Subscriber

Answer: Depending on your pathologist's documentation, this example might justify reporting four units of 88305 (Level IV -- Surgical pathology, gross and microscopic examination...).

Because these are unlisted specimens, you should code according to your pathologist's judgment of the amount of work that each specimen requires. Based on the documentation that the pathologist receives four distinctly identified anal specimens, you should code each one individually.

The only listed anus specimen for pathology is 88304 (Level III -- Surgical pathology, gross and microscopic examination, anus, tag). Because the specimens you describe are for evaluation for cancer or pre-cancerous changes, your pathologist might find the work associated with the evaluation similar to a biopsy instead of an anus tag. You would code a biopsy as 88305 for most tissue types, so 88305 might be the most appropriate code for these anus specimens.

Do this: CPT instruction states, "Any unlisted specimen should be assigned to the code which most closely reflects the physician work involved when compared to other specimens assigned to that code." If the pathologist judges each specimen to involve work comparable to a biopsy, you should report this case as 88305 x 4.