Pathology/Lab Coding Alert
Specimen Not Too Small if You Do the Work
Nevada Subscriber
Answer: As long as the pathologist has adequate tissue, no matter how small, to perform both procedures, you can and should report both services. If the pathologist performs a frozen section consultation on the punch skin biopsy, report 88331 (Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen).
The following day, if the pathologist performs an exam of permanent-section slides prepared from the biopsy, even if the lab had previously called the tissue the "frozen section control," you should report that service as 88305 (Level IV - Surgical pathology, gross and microscopic examination, skin, other than cyst/tag/
debridement/plastic repair). It's all in the documentation - make sure the pathology report lists all the services that were rendered.
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