Pathology/Lab Coding Alert

Question: If a surgeon submits multiple needle core breast biopsies in a single container, is the pathologist required to bill only one unit of service?

Michigan Subscriber

Answer: The pathologist is not always constrained to report one unit of service for multiple breast biopsies submitted in a single container. Correct coding for the case requires more information.

You should report a needle core breast biopsy as 88305 (Level IV - Surgical pathology, gross and microscopic examination, Breast, biopsy, not requiring microscopic evaluation of surgical margins). As with all surgical pathology tissue exams, the unit of service for a breast biopsy is the specimen, “submitted for individual and separate attention, requiring individual examination and pathologic diagnosis.” 

Surgeons will often submit different specimens in separate containers, but not always. They may submit different specimens in the same container and separately identify them with a mark (such as a suture). If multiple specimens are in the same container, the surgical note should describe the distinct specimens based on the unique anatomic site and/or surgical session of origin. 

If the pathologist proceeds to individually examine and diagnose the uniquely identified needle core biopsies, you should report each as a unit of 88305.

However, if the surgeon submits multiple needle core breast biopsies in a single container with no distinction or identification of distinct specimens, generally, you should report only one unit of 88305 for the pathologist’s work.