Pathology/Lab Coding Alert

Question: Our pathologist examined a specimen that the surgeon identified as "soft tissue mass, right thigh." The final diagnosis in the pathology report was "lipoma." We’re having a disagreement in the office whether this specimen earns 88304 or 88307 — could you make the call?

Kentucky Subscriber

Answer: The correct procedure code for your pathologist’s specimen evaluation in this case is 88304 (Level III - Surgical pathology, gross and microscopic examination, Soft tissue, lipoma).

You should not code the service as 88307 (Level V - Surgical pathology, gross and microscopic examination, Soft tissue mass [except lipoma] - biopsy/simple excision).

Although the surgeon identifies the specimen as "soft tissue mass," the final diagnosis assigned by the pathologist is lipoma. You should always code according to the final diagnosis, when available.

In addition to 88304 providing the most specific diagnosis — lipoma — you’ll also notice that 88307 excludes lipoma from the code descriptor.