Pathology/Lab Coding Alert

Question: I'm coding a pathology report that describes examination of a cystectomy specimen. The report states that the pathologist received in a single container, the bladder resection with short, attached urethra and ureter segments, as well as fatty tissue containing a four lymph nodes. Is this all one specimen, and how should we code it?

North Carolina Subscriber

Answer: You should report one code for the excised bladder with attached pieces of urethra and ureters as 88309 (Level VI - Surgical pathology, gross and microscopic examination ... Urinary bladder, partial/total resection ...).

Although ureter and urethra segments are listed specimens under 88305 (Level IV - Surgical pathology, gross and microscopic examination ... Ureter, biopsy, Urethra, biopsy ...), you should not separately report those segments in this case. Because the specimen is a bladder resection, and the small, attached pieces of urethra and ureter essentially represent the resection margin, you should bundle those into the larger specimen.

On the other hand, the lymph nodes are separately billable, even though the surgeon didn't submit the nodes in a separate container.

Here's why: Bladder specimens don't typically come to the pathologist with lymph nodes attached. By coding convention, you can separately bill for the lymph node exam for specimens that don't typically involve lymph nodes, even if the surgeon submits the tissue in a single container, as long as the pathologist separately identifies, examines, and reports on the lymph nodes.

Because the fatty tissue contains several lymph nodes, you should report the additional pathology exam as 88307 (Level V - Surgical pathology, gross and microscopic examination ... Lymph nodes, regional resection ...).