Pathology/Lab Coding Alert

Question: During hip replacement surgery for a patient with severe osteoporosis, the surgeon submits the femoral head and fracture fragments from the acetabulum for pathologic diagnosis. Our pathologist decalcifies the tissue from both specimens. They process the femoral head in two cassettes labeled A1 and A2. The pathologist also processes the acetabulum bone fragments in a separate cassette labeled Specimen B1. How should we code the pathologist’s work?

Oklahoma Subscriber

Answer: For the pathology exam of the femoral head removed for hip replacement, report one unit of 88304 (Level III - Surgical pathology, gross and microscopic examination, … femoral head, other than fracture…) for Specimen A processed in two cassettes A1 and A2. That’s the correct code even though the patient has osteoporosis, because you don’t provide any indication of fracture.

Based on your question, neither the surgeon’s submission nor the pathologist’s diagnosis indicates that the femoral head is fractured. If you have such documentation, you should instead report Specimen A processed in two cassettes using a single unit of 88305 (Level IV - Surgical pathology, gross and microscopic examination, … femoral head, fracture…).

For the examination of fracture fragments of acetabulum, you should list the pathologist’s work using 88307 (Level V - Surgical pathology, gross and microscopic examination … Bone fragment(s), pathologic fracture …).

Avoid: Because the pathologist doesn’t receive or examine the entire joint, you should not report the pathologist’s work in this case using 88305 (… joint, resection …). That code is more common for knee replacement cases.

Decal: You have documentation that the pathologist decalcified bone from both specimens. That means you should list two units of +88311 (Decalcification procedure (List separately in addition to code for surgical pathology examination)) for this case.