Pathology/Lab Coding Alert

You Be the Coder:

Specimen Not Too Small if You Do the Work

Question: If the pathologist examines frozen sections from a small punch skin biopsy during surgery and has nothing left but the frozen section control block for the biopsy exam, can we report both CPT 88331 and 88305? We typically take the frozen section control out of the cryostat and put it in formalin to process the next day so that the pathologist can examine the slides. The pathologist provides a diagnosis from the frozen section and the frozen section control processed in formalin.

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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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