Pathology/Lab Coding Alert

Question: The surgeon submitted two fibroids from different anatomic sites from a patient with endometriosis. The surgeon identified one myoma from the cervix and one from the fundus of the uterus. Should we bill this as one or two units?

Washington Subscriber

Answer: If the surgeon separately identifies the two myomas from distinct anatomic sites and the pathologist separately examines and diagnoses the two specimens, you should bill two units of 88305 (Level IV - Surgical pathology, gross and microscopic examination, … leiomyoma(s), uterine myomectomy - without uterus …).

Surgeons often submit one or more leiomyomas for an endometriosis case without distinguishing the tissue as separate specimens. If that were the case in this scenario, you would bill just one unit of 88305.