Pathology/Lab Coding Alert

Question: The surgeon requests an intraoperative consultation for a lumpectomy specimen, first for a preliminary diagnosis, but also to evaluate the marked medial and lateral margins to see if they’re clear.

The pathologist performs a rapid microscopic examination of the lumpectomy specimen as a whole using frozen section technique (one block) and assigns an immediate diagnosis of “infiltrating ductal carcinoma.”

The pathologist then evaluates the two distinct margins by touch preparation technique to ensure a broad surface area of each margin for evaluation. After individually examining each margin separately under the microscope, the pathologist reports, “medial margin: no tumor present; lateral margin: no tumor present.”

After reporting the findings, the surgeon proceeds to close the surgical field. How should we code this?

Arkansas Subscriber

Answer: The lumpectomy in this case represents the specimen, but the pathologist examines three different sites from the specimen that you should code individually. The three sites/services are the frozen block from the tumor, plus the separately marked medial and lateral resection margins. Each site is medically significant to the patient’s care and treatment. Neither touch preparation exam in any way duplicates the frozen section exam.

You should report the frozen section lumpectomy exam using 88331 (Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen). You should additionally report two units of +88334 (Pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), each additional site (List separately in addition to code for primary procedure)) for the intraoperative touch preps on the two distinct margin sites.

Key: CPT^® instruction allows you to report +88334 in addition to an initial frozen section exam (88331), not just an initial touch prep exam (88333, Pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), initial site).

Edits: Because National Correct Coding Initiative (NCCI) edits lists +88334 as a column 2 code with 88331, you will need to use an appropriate modifier, such as 59 (Distinct procedural service) with +88334.

Don’t forget: When the pathologist performs the final diagnosis of the lumpectomy specimen, you should also report 88307 (Level V - Surgical pathology, gross and microscopic examination … Breast, mastectomy - partial/simple …) for the case.