Pathology/Lab Coding Alert

Question: Should we code the pathology exam of needle-core biopsy specimens as 88305 or 88307?


Ohio Subscriber


Answer: Needle-core biopsy tells you two things: it describes how the surgeon took the specimen, and it defines the specimen as a biopsy (partial removal with no margins), not a resection. But that is not enough information to select the proper surgical pathology code.

You also have to know what organ the specimen comes from. CPT lists nearly 50 biopsy specimens, and the vast majority fall under 88305 (Level IV--Surgical pathology, gross and microscopic examination), from A (abortion) to V (vulva/labia biopsy). You should report any biopsy from one of these listed specimens as 88305, regardless of whether the surgeon extracted the biopsy using a needle-core or another method.

CPT also lists several biopsy specimens under 88307 (Level V--Surgical pathology, gross and microscopic examination), only one of which specifies needle biopsy (liver, biopsy--needle/wedge). But as with 88305, the code definition does not have to specify “needle-core” biopsy for you to select 88307--it just has to be a biopsy specimen listed under 88307, such as pancreas, biopsy.