Pathology/Lab Coding Alert

You Be the Coder:

Don't Let 'Container' Fool You

Published on Wed Aug 06, 2014

Question: The pathologist received a single specimen container with tissue identified by the surgeon as “hernia sack and cord lipoma.” The pathologist separately evaluates and diagnoses the hernia sack and the lipoma. Can we separately charge for both, and if so, what codes should we use?

Mississippi Subscriber

Answer: Yes, you can separately bill for two specimens in this scenario. The correct coding is 88304 (Level III - Surgical pathology, gross and microscopic examination… Soft tissue, lipoma…) and 88302 (Level II - Surgical pathology, gross and microscopic examination…, Hernia sac, any location…).

Even though the hernia sac and the cord lipoma come in the same container, you indicate that the surgeon separately identified the tissues in the report. Because the surgeon separately identifies two specimens and the pathologist documents two specimen exams, you should bill each service separately.

Coder tip: The number of specimens, not the number of containers, should drive coding for surgical pathology. If the surgeon submits multiple specimens in one container, a distinguishing mark, such as a suture, or a surgical note may help distinguish the tissues. The pathologist should document separate examination and diagnosis when evaluating multiple specimens.