Pathology/Lab Coding Alert

Question: Our pathologist examined a specimen from a tonsillectomy and adenoidectomy that the surgeon submitted in one container, but it also included a tagged lymph node that the surgeon described in the report as “a large mass in the retropharyngeal space.” How should we code the pathology exam?

Tennessee Subscriber

Answer: Report the surgical pathology exam of the tonsils and adenoids as 88304 (Level III - Surgical pathology, gross and microscopic examination … Tonsil and/or adenoids …).

Because the surgeon separately identifies the “mass,” which turns out to be a lymph node, you should bill an additional code for that pathology exam using 88305 (Level IV - Surgical pathology, gross and microscopic examination … lymph node, biopsy …).