Pathology/Lab Coding Alert

Question: Our pathologist evaluated a colon resection during surgery by performing frozen section exams on two resection margins and squash preps on one of the margins. How should we code the case?

Iowa Subscriber

Answer: Report the intraoperative frozen section exams of two distinct margins using the following codes:

• 88331 (Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen)
• +88332 (Pathology consultation during surgery; each additional tissue block with frozen section(s) (List separately in addition to code for primary procedure)).

Missed opportunity: The pathologist should always document the number of blocks for frozen-section evaluation of the margins. If the pathologist examined frozen sections from more than two blocks, you could report additional units of +88332.

For the touch prep examination during surgery in this case, you should also report +88334 (Pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), each additional site (List separately in addition to code for primary procedure)).

Don’t miss: Coders often think that a case like this warrants reporting 88333 (Pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), initial site) for the touch preps, because it is the “initial site” for that procedure. But a CPT^® text note states, “For intraoperative consultation on a specimen requiring both frozen section and cytologic evaluation, use 88331 and 88334.”