Pathology/Lab Coding Alert

Question: Our pathologist examined a right breast biopsy specimen and diagnosed the tissue as a lipoma. How should we code this?

Tennessee Subscriber

Answer: The proper diagnosis code is D17.1 (Benign lipomatous neoplasm of skin and subcutaneous tissue of trunk), which is critical to note when selecting the proper procedure code. Based on the diagnosis, you should code the pathologist’s exam as 88304 (Level III - Surgical pathology, gross and microscopic examination ... soft tissue, lipoma).

Exception: According to ICD-10 code definitions and neoplasm table, you should list most benign neoplasms with a code based on the tumor location, such as D24.1 (Benign neoplasm of right breast). But ICD-10 has separate codes for lipoma, which can occur at just about any location in the body (D17. -, Benign lipomatous neoplasm …).

Once the physician (the pathologist in this case) has assigned a final diagnosis, you should code the confirmed or definitive diagnosis, according to ICD-10 guidelines.

And once you’ve assigned a diagnosis, the pathology procedure code must align with it. That’s why you need to report the pathology exam as 88304 instead of 88305 (Level IV - Surgical pathology, gross and microscopic examination … Breast, biopsy, not requiring microscopic evaluation of surgical margins).