Pathology/Lab Coding Alert

Question: The pathologist examined a colon biopsy from a patient having a diagnostic colonoscopy due to prior polyp findings. The diagnosis for the specimen was "mild epithelial hyperplasia, colon." How should we code the case?

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Answer: The correct procedure code is 88305 (Level IV - Surgical pathology, gross and microscopic examination, colon, biopsy).

Because the pathologist's findings of "mild epithelial hyperplasia, colon" essentially means that the tissue is normal, you should list the diagnosis as the physician's ordering diagnosis. For instance, the physician might assign V12.72 (Personal history of colonic polyps), and that's the code the pathologist would use.

When the pathology report indicates more specific findings, you should report that diagnosis. For instance, if the pathologist had diagnosed an adenomatous polyp, you would list the diagnosis as 211.3 (Benign neoplasm of colon) instead of reporting the ordering diagnosis.