Pathology/Lab Coding Alert

Question: The pathologist examined the contents of a container submitted from an endoscopic sinuplasty surgery. The tissue included mucous membrane, nasal polyps, scar tissue, and a bit of septum. How should I code this?

Arkansas Subscriber

Answer: Because the surgeon does not submit any of the elements in the container for separate evaluation, you need to assign a single code for the nasal contents as a single specimen. The best choice is 88304 (Level III - Surgical pathology, gross and microscopic examination … Polyps, inflammatory - nasal/sinusoidal …)

Because there’s no indication that the surgeon removed a specific area of concern for a biopsy to evaluate for neoplasm, you should not use 88305 (Level IV - Surgical pathology, gross and microscopic examination … Nasal mucosa, biopsy …).

Sinuplasty surgery is essentially a debridement of the nasal cavity and may include a number of elements such as you described. The contents represent a single unit of 88304, in this case. If the surgeon had separately submitted right and left nasal contents, you could code 88304 x 2.

Ancillary: Because you mentioned that the specimen included a piece of septum, which is bony/cartilage tissue, you should be on the lookout for documentation of decalcification. If you see that procedure listed in the pathology report, you should also code +88311 (Decalcification procedure (List separately in addition to code for surgical pathology examination)).