Pathology/Lab Coding Alert

Question: If our pathologist receives needle core prostate biopsy specimens in two containers, one labeled right and the other labeled left, with four distinct cores in each container, how should we code this? Louisiana Subscriber Answer: Pathologists often examine multiple needle core prostate biopsies, and you can report each distinct examination as one unit of 88305 (Level IV -- Surgical pathology, gross and microscopic examination,prostate, needle biopsy). Stipulation: The key to answering your question is understanding what constitutes a distinct specimen that warrants an individual examination. Because the physician separately identifies only two specimens in your example -- left and right -- you should code only two units of 88305. Thats the case, despite each container holding four separate cores. Although prostate biopsies often involve about 12 separate needle cores, the diagnostic value of multiple specimens involves a systematic sampling that identifies the location of each core. By lumping multiple cores in [...]