Pathology/Lab Coding Alert

Answer: Code CPT 88305 (level IV, surgical pathology, gross and microscopic examination; skin, other than cyst/tag/debridement/plastic repair) is to be used for any skin specimen except cyst, tag, debridement or from plastic repair. Therefore, 88305 would be the correct code for the specimen you described because it is identified as a skin lesion, and it is not one of the four exceptions.

The answer lies in the description of the specimen. Inking does not alter the specimen source, so the fact that the tissue is inked does not permit upcoding. The specimen is not identified as a soft tissue mass, even though it may include some subcutaneous tissue. As such, it does not justify an 88307 (level V, surgical pathology, gross and microscopic examination; soft tissue mass [except lipoma] biopsy/simple excision), and certainly not 88309 (level VI, surgical pathology, gross and microscopic examination; soft tissue tumor, extensive resection).

Editors note: Susan Callaway-Stradley, CPC, CSS-P, an independent coding consultant and educator in North Augusta, S.C.; and Laurie Castillo, MA, CPC, president of the American Association of Professional Coders Northern Virginia Chapter and owner of Physician Coding & Compliance Consulting in Manassas, Va., provided advice to answer this question.