Pathology/Lab Coding Alert

Question: Our pathologist received a cervical LEEP specimen from a colposcopy with a loop electrocautery biopsy of the cervix, and the pathology report identifies the specimen as a cervical biopsy. The diagnosis is CIN III. How should I code the case?

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Answer: The correct procedure code for the pathologist’s evaluation of a loop electrosurgical excision procedure (LEEP) cervical biopsy is 88305 (Level IV, Surgical pathology, gross and microscopic examination ... Cervix, biopsy ...).

Caution: Cervical LEEP is not a listed specimen in the CPT^® surgical pathology codes, so the tissue exam may be properly listed as a cervix biopsy (88305) or cervix conization (88307, Level V, Surgical pathology, gross and microscopic examination ... Cervix, conization ..), depending on the details of the case. You state the surgeon performed a biopsy, and the pathology report identifies the tissue as a cervical biopsy, so the appropriate charge is 88305.

Note: Surgeons may report a LEEP biopsy procedure, such as 57460 (Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix), or a LEEP conization procedure, such as 57461 (… with loop electrode conization of the cervix)

If the op report is ambiguous about the LEEP specimen, some anatomic knowledge can help you choose the correct code. Generally speaking, a LEEP biopsy samples only as high as the transformation zone, while a LEEP conization involves removing a tissue “cone” that takes the ectocervix, transformation zone, and goes up into the endocervix.

Diagnosis: The correct code for the pathologist’s diagnosis is D06.7 (Carcinoma in situ of other parts of cervix). This code has an Includes note for cervical intraepithelial neoplasia III [CIN III].