Pathology/Lab Coding Alert

Question: Our pathologist examines a partial mastectomy specimen and a sentinel lymph node specimen from the axillary node basin of the same breast. Because CPT bundles lymph nodes with mastectomy specimens, should we code this as 88309?


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Answer: You should not code this scenario as 88309 (Level VI--Surgical pathology, gross and microscopic examination, breast, mastectomy--with regional lymph nodes). Although CPT bundles regional lymph nodes with a mastectomy specimen, there are two reasons you should not report the specimens you described as a single unit of 88309:

1. The pathologist examined a sentinel node, not a regional lymph node resection. A regional lymph node resection is the tissue included in an 88309 total mastectomy. The sentinel node is a separate listed specimen that requires far more physician work than a typical lymph node examination.

A sentinel node involves serial sectioning and special staining at multiple levels. That's why CPT assigns a sentinel node to the same work category as a regional lymph node dissection, which may involve multiple nodes: 88307 (Level V--Surgical pathology, gross and microscopic examination, sentinel lymph node, or ... lymph nodes, regional resection).

2. The pathologists examined a partial mastectomy specimen, not a complete mastectomy. You might also see these specimens called breast quadrantectomy or simple mastectomy. CPT lists this specimen as 88307 (- breast, mastectomy--partial/simple).

CPT lists a total mastectomy as 88309--which includes the entire breast and contiguous or attached lymph nodes.

Do this: You should code the service you described as two units of 88307--one for the partial mastectomy specimen and one for the sentinel lymph node specimen.