Pathology/Lab Coding Alert

Question: Our pathologist examines a portion of rib removed for thoracic outlet syndrome, but doesn’t report a pathologic diagnosis. The path report states, “portion of rib, gross identification only.” What code should we assign?

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Answer: The correct procedure code is 88300 (Level I - Surgical pathology, gross examination only), but perhaps the ICD-9 code is the bigger concern. You should assign the diagnosis code in this case based on the ordering diagnosis. For thoracic outlet syndrome, use 353.0 (Brachial plexus lesions).

Here’s why: ICD-9 (and ICD-10) don’t have codes for “normal tissue.” Whether for 88300 or any other surgical pathology service, if the pathologist doesn’t reach a definitive diagnosis, you should revert to the ordering diagnosis. That’s true even if you only have signs or symptoms, or a reason for the encounter.