Pathology/Lab Coding Alert

Question: An ob-gyn submitted 3 cm sections of right and left fallopian tubes with a surgical note indicating that he removed the tissue as part of a routine sterilization procedure. Our pathologist found evidence of malignant neoplasm, however. What is the correct CPT and ICD-9 coding for this case?

Illinois Subscriber

Answer: You should assign the diagnosis based on the pathologist's findings rather than the surgical report. Instead of using the ICD-9 code indicating that the surgeon submitted the fallopian tubes from a sterilization procedure (V25.2, Sterilization), you should use the code that indicates your pathologist's findings. In this case, list 183.2 (Malignant neoplasm of fallopian tube).

Here's why: The ICD-9-CM Official Guidelines for Coding and Reporting for both inpatients and outpatients state that you should code a confirmed or definitive diagnosis provided by a physician --in this case, the pathologist.

Diagnosis affects charge: This scenario points at an important consideration -- the diagnosis can affect the pathology procedure code in some circumstances. Because the pathologist examines the fallopian tubes for cancer, you should report the service as 88305 (Level IV- Surgical pathology, gross and microscopic examination, Fallopian tube, biopsy) instead of 88302 (Level II -- Surgical pathology, gross and microscopic examination, Fallopian tube, sterilization).