Pathology/Lab Coding Alert

Question: A common specimen for us is one container that includes bilateral palatine tonsils and fragments of adenoids. We can easily distinguish right and left tonsils from adenoids (but not from each other).

Pennsylvania Subscriber

Answer: The example you give warrants one unit of 88304 (Level III -- Surgical pathology, gross and microscopic examination, tonsil and/or adenoids), not two.

Here's why: The CPT descriptor bundles tonsils and adenoids as a single specimen. The "or" in the descriptor means that you should report 88304 if you examine tonsils or if you examine adenoids. The "and" in the descriptor means that you should report 88304 if you examine tonsils and adenoids. In other words, the CPT code bundles those two tissues as a single specimen. You should not unbundle tonsils and adenoids into two specimens, even if you receive them in separate containers or separately identified.

Watch for separate tonsils: On the other hand, you can bill two units of 88304 for distinct tonsil specimens. For instance, you can code 88304 x 2 if the surgeon separately identifies the tonsils by some method and the pathologist separately diagnoses each tonsil. The surgeon might distinguish the tonsils by submitting them in separate containers marked right and left, or by marking one with a suture and identifying the orientation. If you also receive adenoids, even in a third container, you should bundle the adenoidal tissue with either the left or right tonsil.

Don't miss: In your case, you state that you cannot distinguish left and right tonsils from each other, so you should only bill one unit of 88304.