Pathology/Lab Coding Alert
Distinguish Vaginal Tissue Codes
Question: Our pathologist examined tissue from a vaginal mesh removal and reported findings of fibrovascular tissue. Should we code this as 88302 or 88305?
California Subscriber
Answer: The correct procedure code is 88302 (Level II - Surgical pathology, gross and microscopic examination; vaginal mucosa incidental). Even though the findings are “fibrovascular tissue,” not “mucosa,” the key is that this is incidental tissue, and the level of work involved in the pathologist’s evaluation is similar to that for incidental vaginal mucosa.
“Unlisted” rule: Remember that if a surgical pathology specimen is not listed under one of the 88302-88309 codes, you should select the proper code based on the comparable level of work required for the examination.
Not 88305: Although vaginal tissue is also listed under 88305 (Level IV - Surgical pathology, gross and microscopic examination; vagina biopsy), the service you describe does not warrant that code level. In this case, the vaginal tissue is incidental to a surgical procedure to remove the mesh. It is not a biopsy taken with the intention of aiding in diagnosis of a suspected pathological condition.
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Distinguish Vaginal Tissue Codes
Question: Our pathologist examined tissue from a vaginal mesh removal and reported findings of fibrovascular tissue. [...]
