Pathology/Lab Coding Alert

Question: Our pathologist received two very large fibroid specimens in a single container and diagnosed interstitial leiomyoma of uterus. Should we code this as an 88307 specimen based on the size, and how should we code the diagnosis?

Tennessee Subscriber

Answer: No, you should not code this specimen as 88307 (Level V - Surgical pathology, gross and microscopic examination ... Uterus, with or without tubes and ovaries, other than neoplastic/prolapse ...). You should report 88307 for uterine fibroids only when the surgeon performs a hysterectomy for the condition.

Size doesn't matter. You should code this case as 88305 (Level IV - Surgical pathology, gross and microscopic examination, ... leiomyoma(s), uterine myomectomy - without uterus ...) no matter how large the growths. Also notice that the code definition states "leiomyoma(s)," so you should report just one unit of 88305, even though you indicated that the pathologist examined two fibroids. If the surgeon separately submits and identifies the fibroids, you may be able to code them separately, but that is not in evidence in this case.

Regarding the diagnosis, you should list D25.1 (Intramural leiomyoma of uterus). Always code the most specific diagnosis supported by the pathology note as opposed to reporting a less-specific code, such as D25.9 (Leiomyoma of uterus, unspecified).