Pathology/Lab Coding Alert

Question: Please help clarify how to code intramural leiomyoma findings in a uterus specimen. Does leiomyoma classify as a neoplasm?

Texas Subscriber

Answer: Although leiomyoma classifies as a benign neoplasm in ICD-9 (218.1, Intramural leiomyoma of uterus for the specimen you mention), you can't claim a "neoplastic" uterus pathology exam procedure code.

Exception: Even though the intramural leiomyoma is a neoplasm, you shouldn't list 88309 (Level VI -- Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, neoplastic) as the procedure code. Uterine leiomyomas represent an "unwritten" exception among listed specimens in the CPT® surgical pathology section, according to several sources, as follows:

CPT®: The December 2003 CPT Assistant® states that "leiomyomas do not require the same degree of evaluation as other uterine neoplasms," and therefore concludes that when leiomyoma of the uterus is the principal diagnosis for a hysterectomy specimen, you should report 88307 (Level V -- Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, other than neoplastic/prolapse) rather than 88309.

CAP: The College of American Pathologists (CAP) has also published coding advice indicating that you should use 88307 for uterine leiomyoma in addition to non-neoplastic uterine conditions (CAP Today July 1999).

Fibroids are different: When the pathologist examines a myomectomy specimen, which is a resection that involves removing fibroids from the uterus without performing a complete hysterectomy, don't use 88307. CPT® lists this specimen as 88305 (Level IV -- Surgical pathology, gross and microscopic examination, leiomyoma[s], uterine myomectomy -- without uterus).