Pathology/Lab Coding Alert

Question: What are the correct diagnosis and procedure codes for the following specimen: Right epididymis, resection - benign cyst or duct ectasia?


Maryland Subscriber


Answer: The proper ICD-9 code is 608.89 (Other specified disorders of male genital organs, other). Although the examples given for 608.89 in the tabular list (ICD-9 Volume 1) do not include epididymis cyst, you should be able to get to the proper code by looking in the alphabetic index (ICD-9 Volume 2).

If you look under the patient's condition, "cyst," epididymis is a listed specimen, and the listed code is 608.89. You should always select an ICD-9 code by first looking in the alphabetic index, then turning to the tabular list to confirm the proper code.

Choosing the proper CPT code for the pathologist's specimen exam in this case can also be confusing, because epididymis is not a listed specimen.

CPT provides five codes for gross and microscopic examination of surgical pathology specimens: 88302-88309. You choose the proper code by finding the specimen listed under one of the five exam levels. For example, you'd code 88305 for a bone marrow biopsy because it is a specimen listed under 88305 (Level IV - Surgical pathology, gross and microscopic examination, bone marrow, biopsy).

But epididymis is not a listed specimen under any of these codes. For an unlisted specimen, you'll have to "assign the code which most closely reflects the physician work involved when compared to other specimens assigned to that code," according to CPT instruction. Similar specimens that CPT does list might include spermatocele or testicular appendage, both of which fall under 88304 (Level III - Surgical pathology, gross and microscopic examination). For that reason, you should report 88304 for the pathologist's exam of the epididymis resection.