Pathology/Lab Coding Alert

You Be The Coder:

Needle Localization Breast Biopsy

Published on Fri Nov 01, 2002

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.

Question: We received a needle localization of the breast in a single container. Using x-ray and frozen sections, we recognized two areas of microcalcification requiring separate identification. One was malignant and required evaluation of the margin. Should this be billed as CPT 88307 and 88305?

Maine Subscriber

Answer: No, you should not report both 88305 (Level IV Surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins) and 88307 (Level V Surgical pathology, gross and microscopic examination, breast, excision of lesion, requiring microscopic evaluation of surgical margins) in this instance. The physician submitted a needle localization breast biopsy, which is a single specimen. Because the specimen requires evaluation of margins, report 88307.

Although the surgeon gave you one piece of tissue, you performed frozen sections on the separately identified microcalcifications. Capture this service by reporting 88331 (Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen) for the frozen section from the first microcal-cification and 88332 (each additional tissue block with frozen section[s]) for the second microcalcification frozen section. Report these codes in addition to the 88307 for the breast lesion examination.