Pathology/Lab Coding Alert

Question: The pathology report states that the specimen received is a bladder biopsy, and that the procedure was a transurethral resection (TUR) for bladder tumor. Should we code this as 88305 or 88307?

Arkansas Subscriber

Answer: If the pathologist designated the specimen as a bladder biopsy, you should code the procedure as 88305 (Level IV - Surgical pathology, gross and microscopic examination…, Urinary bladder, biopsy…).

You are correct that the stated surgical procedure, transurethral resection (TUR) for bladder tumor, introduces some ambiguity in the proper code selection. Pathologic diagnosis of a urinary bladder TUR specimen takes a different procedure code — 88307 (Level V - Surgical pathology, gross and microscopic examination…, Urinary bladder, TUR…).

Bottom line: You should code based on the pathologist’s determination and designation of the specimen at hand. If the pathologist had referred to the specimen as a urinary bladder TUR in the pathology report, billing 88307 would be the better choice.

Coder tip: This is the type of scenario that could benefit from a conversation with the pathologist. Doing so could both clarify appropriate coding for this case, and also educate the pathologist about the need for intentionally choosing words in the pathology report that clarify the specimen in light of CPT^® language.