Pathology/Lab Coding Alert

Question: The pathologist examines a "simple prostatectomy" specimen with four right-pelvic lymph nodes. I know that "radical resections" often include lymph nodes, so should we code this as 88309?

Utah Subscriber

Answer: No, you should not code this case as 88309 (Level VI -- Surgical pathology, gross and microscopic examination, prostate, radical resection).

Instead, you should report the case as follows:

• 88307 -- Level V -- Surgical pathology, gross and microscopic examination, prostate, except radical resection
• 88307 -- ... lymph nodes, regional resection.

Lymph nodes are separate: Although you're correct to state that lymph nodes are bundled with many radical resection specimens, such as total mastectomy, that's not the case for prostate. The surgeon does not typically remove regional lymph nodes associated with the prostate, so you should code those separately if the pathologist examines them. If the pathologist examines two regional lymph resections, such as the left and right pelvic lymph nodes, you can report two units of 88307.

'Simple' vs. 'radical': If the pathology report states "simple" or "subtotal" prostatectomy, that means that the specimen is not a radical (total) resection and you shouldn't report 88309. To warrant coding for a radical prostate resection, the pathologist must examine the entire prostate, including the capsule and attached seminal vesicles, and possibly other material such as surrounding fatty tissue, and prostate/bladder neck junction. Only then should you list 88309.

Don't bundle: You always hear that you shouldn't unbundle specimens, but the reverse is true. You shouldn't take two distinct specimens and bundle them into a single surgical pathology code. You should always use the listed specimens under codes 88302-88309 for gross and microscopic pathology exams, even if that means reporting multiple codes.