Pathology/Lab Coding Alert

Question: Our pathologist received several “shave” tissue slices from a bladder TURBT procedure, with one slice inked and identified as “deep margin.” The pathologist diagnosed low grade urothelial carcinoma stage 1 because the deep margin showed invasion into the lamina propria but no involvement of the muscle of the bladder wall. How should we code this case?

Tennessee Subscriber

Answer: You’ve described a urinary bladder specimen acquired through a transurethral resection of bladder tumor (TURBT) procedure. You should code the multiple “shaves” that aren’t separately identified as a bladder TURBT specimen using 88307 (Level V - Surgical pathology, gross and microscopic examination … Urinary bladder, TUR …).

When performing cystoscopy through the urethra and using the resectoscope, the surgeon often resects a bladder tumor in numerous “shaves” that are extensive enough to determine if the cancer is invasive. “The tumor pieces represent a single TUR specimen, not multiple specimens,” says R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services in Jonesboro, Ark.

Exception: Because the surgeon separately identified the deep margin and the pathologist separately evaluated that specimen, you may additionally report 88305 (Level IV - Surgical pathology, gross and microscopic examination … Urinary bladder, biopsy …), according to Stainton.

Diagnosis: Urothelial carcinoma in the urinary bladder is a malignant neoplasm. Because you don’t specify the specific location of the lesion within the bladder, the best diagnosis code choice for this case is C67.9 (Malignant neoplasm of bladder, unspecified). ICD-10-CM code C67 requires a fourth character, which specifies the site within the bladder. If the surgeon documented that information, you might choose a different code, such as C67.2 (Malignant neoplasm of lateral wall of bladder) for a tumor on the lateral wall.