Pathology/Lab Coding Alert

Question: Our pathologist examined two frozen section blocks during surgery from the patient's right thyroid lobe. Because of thyroid cancer findings, the surgeon proceeded to remove the left thyroid lobe, and the pathologist examined two additional frozen section blocks from that side. Later, the pathologist examined and diagnosed each thyroid lobe. How should we code the case?

Tennessee Subscriber

Answer: CPT provides a code for a total thyroidectomy -- and the same code for a thyroid lobe resection -- 88307 (Level V -- Surgical pathology, gross and microscopic examination, thyroid, total/lobe). That means you must first decide whether you have two specimens (two thyroid lobes) or a single specimen (a total thyroidectomy).

Because the surgeon separately removed and submitted each thyroid lobe to the pathologist for individual examination and diagnosis, this case represents two separate specimens. You should list two units of 88307 -- one for each lobe.

Caution: You-ll need to follow your payer's convention to indicate that you-ve performed two distinct services, such as reporting 88307 x 2 or listing the second code with modifier 59 (Distinct procedural service).

Frozens are separate: In addition to reporting the pathologist's surgical-pathology specimen exam, you also need to bill for the frozen sections. For the first consultation with two frozen-section blocks from the right thyroid lobe, you should report 88331 (Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen) for the first frozen-section block and 88332 (... each additional tissue block with frozen section[s]) for the second block.

You would report the two frozen section blocks from the subsequent left thyroid lobectomy the same way -- 88331 plus 88332.

Case codes: In summary, for the entire case, you should report the following codes:

• 88331 x 2
• 88332 x 2
• 88307 x 2.