Pathology/Lab Coding Alert

Question: Our pathologist examined two colon biopsies identified by location. The service also included a consult during surgery involving a frozen section and touch prep for one biopsy and two touch preps for the other. How should I code this? 

 
Tennessee Subscriber

Answer: For each colon biopsy, report 88305 (Level IV--Surgical pathology, gross and microscopic examination, colon, biopsy). Because each biopsy is from a distinct location and requires a separate diagnosis, you can report 88305 x 2.

For the frozen sections and touch preps, you should also code the work for each specimen separately. For the specimen involving one frozen section and one touch prep, use 88331 (Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen) and 88334 (... cytologic examination [e.g., touch prep, squash prep], each additional site). Although this is the initial site, you cannot report 88333 (... cytologic examination [e.g., touch prep, squash prep], initial site) because CPT directs coders to use 88331 and 88334 for an intraoperative consultation on a specimen that requires both frozen section and cytologic evaluation.

For the specimen requiring two touch preps, report 88333 and 88334. Because the second biopsy represents a separate specimen, you should use 88333 to describe the first touch prep as the "initial site" from that specimen. You should not count the touch prep from the other specimen as the initial site. 

Reader Questions and You Be the Coder were prepared with the assistance of R. M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.