Pathology/Lab Coding Alert

Question: How should we use the frozen section codes for the following situation: The pathologist examines frozen sections from two tissue blocks prepared from the surgical specimen, then examines frozen sections from the surgical margins that the surgeon submits at a later time to determine if the margins are clear.


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Answer: The example includes two separate specimens that the surgeon submits for frozen section examination. The first specimen includes two tissue blocks, and you should code the work as follows:

 88331 (Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen)

 88332 (Pathology consultation during surgery; each additional tissue block with frozen section[s]) For the separately-submitted surgical margin specimen, report 88331. That means you're reporting two units of 88331 and one unit of 88332. You should follow your payer's direction for reporting multiple units of a surgical pathology service. You may need to report 88331 x 2, or you may need to submit 88331 with modifier -59 (Distinct procedural service), depending on your payer's instruction.

The key to properly coding this scenario is not the number of blocks the pathologist examined, but the number of specimens. If you had three tissue blocks from the same specimen, the correct codes would be 88331 and 88332 x 2. You should always report 88331 for the first tissue block from a given specimen. Only report 88332 for additional blocks from the same specimen.