Pathology/Lab Coding Alert

Question: Our pathologist diagnosed an enterectomy “specimen A” as adenocarcinoma. From the same surgical session, the pathologist also evaluated two intestine “donut” specimens marked and separately submitted by the surgeon as the proximal and distal margins and labeled B1 and B2. How should I code the pathologist’s work?

Montana Subscriber

Answer: You should code the pathologist’s surgical pathology exam of specimen A, the small bowel resection specimen that is malignant, as 88309 (Level VI - Surgical pathology, gross and microscopic examination… Small intestine, resection for tumor…).

An intestinal “donut” is not a listed surgical pathology specimen. But because the surgeon separately submitted the distal and proximal surgical margins for separate examination and the pathologist separately examines the tissue, you should code each according to the pathologist’s effort as compared to listed specimens.

Because the enterectomy specimen is cancerous, the pathologist’s evaluation of each margin would probably be similar to a biopsy exam for malignancy. If adequately documented in the pathology report, you could report the two “donut” exams as two units of 88305 (Level IV - Surgical pathology, gross and microscopic examination… Small intestine, biopsy…).