Pathology/Lab Coding Alert

Question: We have a pathology report for a breast biopsy exam from a 67 year old male patient. The pathologist diagnoses the specimen as DCIS. What are the correct procedure and diagnosis codes?

Connecticut Subscriber

Answer: The correct procedure code for a breast biopsy is 88305 (Level IV - Surgical pathology, gross and microscopic examination… Breast, biopsy, not requiring microscopic evaluation of surgical margins…).

Although not common in men, you should report the pathology findings of ductal carcinoma in situ (DCIS) as D05.10 (Intraductal carcinoma in situ of unspecified breast) since you don’t state whether this is the right or left breast.

Invasive difference: If the pathology report had indicated invasive or infiltrating ductal carcinoma instead of “in situ,” you would turn to a different code family. Infiltrating ductal carcinoma is a malignant tumor, so you would code that condition to the C50 (Malignant neoplasm of breast) family.

You must report a code from the C50 family to the 7th character. More details in the code will tell you where in the breast the tumor is located, whether the patient is male or female, and if the specimen is from the right or left breast. We don’t have a lot of that information in this case, but you still need to code to the 7th character. The correct code is C50.929 (Malignant neoplasm of unspecified site of unspecified male breast).