Pathology/Lab Coding Alert

Question: What is the correct procedure code for our pathologist's examination of a specimen labeled "trigone of bladder"?

Texas Subscriber

Answer: Your question doesn't provide enough information to determine the appropriate procedure code.

"Trigone" simply refers to an anatomical triangular region of the urinary bladder located at the juncture of the two ureteral openings and the urethral orifice. The designation is not pertinent to your code choice.

The pathologist may receive a urinary bladder biopsy, a urinary bladder trans-urethral resection (TUR), or a urinary bladder partial resection invol ving the urinary bladder trigone. The coding will be different depending on that distinction, as follows:

• 88305 -- Level IV - Surgical pathology, gross and microscopic examination, urinary bladder, biopsy
• 88307 --Level V - Surgical pathology, gross and microscopic examination, urinary bladder, TUR
• 88309 -- Level VI - Surgical pathology, gross and microscopic examination, urinary bladder, partial/total resection.

Based on information from the surgical note and the size of the specimen, your pathologist will have to determine which of these codes best represents the surgical specimen at hand. He should then document the specimen type in the pathology report using the appropriate terminology: biopsy, TUR, or partial resection.