Pathology/Lab Coding Alert

Question: We sometimes have pathology reports for hysterectomy with a pre-op diagnosis of uterine prolapse. If the pathologist's findings indicate other pathology, such as leiomyomas or adenomas, should we report 88305 for the prolapse, or choose a different procedure code based on the pathologist's findings?

Florida Subscriber

Answer: You should base the code for the pathologist's work on the findings, if available at the time of billing, rather than the pre-operative diagnosis.

That means you should not bill a hysterectomy using 88305 (Level IV -- Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, for prolapse) if the pathologist diagnoses additional pathology, even if the pre-op diagnosis is "prolapse."

Do this: For neoplastic findings, such as adenocarcinoma (179, Malignant neoplasm of uterus, part unspecified), report the pathologist's work as 88309 (Level VI -- Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, neoplastic).

For other uterine pathology, such as endometriosis (617.0, Endometriosis of uterus), bill the pathologist's work as 88307 (Level V -- Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, other than neoplastic/prolapse).

Know the quirk: Although fibroid tumor (leiomyoma) is a type of neoplasm, you should report a hysterectomy for leiomyoma as 88307 rather than 88309, based on long-standing coding convention.