|
Answer: The correct code for tonsils that are diagnosed with lymphoma is 88309 (level VI - surgical pathology, gross and microscopic examination, tongue/tonsil - resection for tumor).
The CPT direction for surgical pathology states, "Levels 88302 through 88309 are specifically defined by the assigned specimens." Several tissues are assigned to different levels based on the diagnosis. Tonsil is one of these tissues, with a listing in 88304 (level III - surgical pathology, gross and microscopic evaluation, tonsil and/or adenoids), 88305 (level IV - surgical pathology, gross and microscopic evaluation, tonsil, biopsy) and 88309.
Other examples of tissue reported in this way include uterus and breast. For example, uterus appears under 88305 as uterus, with or without tubes and ovaries, for prolapse; under 88307 as uterus, with or without tubes and ovaries, other than neoplastic/prolapse; and under 88309 as uterus, with or without tubes and ovaries, neoplastic.
Evaluation of breast tissue appears under 88305 as breast, biopsy, not requiring microscopic evaluation of surgical margins; and breast, reduction mammoplasty. It appears under 88307 as breast, excision of lesion, requiring microscopic evaluation of surgical margins; and breast, mastectomy - partial/simple. Breast tissue appears under 88309 as breast, mastectomy - with regional lymph nodes.
Aside from those tissues that are specifically listed under different surgical pathology levels, assigning a listed specimen to a higher level based on diagnosis would be inappropriate. |
