Pathology/Lab Coding Alert

Question: The pathology report documents a “radical nephrectomy” and provides gross and  microscopic descriptions and diagnoses for a kidney,adrenal gland, and mesenteric lymph nodes. How should I report this case?

Texas Subscriber

Answer: You should report the nephrectomy as 88307 (Level V -- Surgical pathology, gross and microscopic examination, kidney, partial/total nephrectomy). You can list the adrenal gland as an additional 88307 (… adrenal, resection). Code the regional mesenteric lymph node resection as another 88307 (… lymph nodes, regional resection).

CPT does not provide a code for a “radical” nephrectomy. You will find radical resection codes that include associated tissue for some other specimens, however, and that can confuse you if you try to apply the concept to nephrectomy.

For instance: A radical hysterectomy for cancer involves removing the uterus, tubes, and ovaries. Because CPT provides a code for this specimen (88309, Level VISurgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, neoplastic), you should bundle the uterus with associated structures.

Difference: A nephrectomy does not typically include the renal gland or regional lymph nodes. Because there is not a radical resection code for the kidney that bundles these tissues, you should code each separate specimen that the pathologist diagnoses. CPT coding principles indicate that the specimen is the unit of service for surgical pathology codes 88300-88309, and defines the specimen as tissue that requires “individual examination and pathologic diagnosis.” That’s why the pathology report must document the separate tissue examination and diagnosis for you to report multiple units of 88307 in this case.

Caveat: The College of American Pathologists (CAP) agrees that the adrenal gland is “not intrinsic to a nephrectomy” (CAP Today July 2008). But instead of reporting 88307 (the listed adrenal gland code), CAP recommends considering the adrenal gland an “unlisted specimen when it is attached to the kidney,” and assigning the code based on the work involved in its examination.