You Be the Coder:
Unlabeled Specimens
Published on Mon Apr 01, 2002
Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: We received a container with three skin biopsies. The biopsies were not separately labeled or identified as to the source. Should this be reported as CPT 88305 or 88305 x 3?
Maryland Subscriber
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Answer: The correct billing would be 88305 (Level IV Surgical pathology, gross and microscopic examination) because there is no distinct identification to indicate separate specimens. If something distinguished the three, such as an ink mark or a surgical note referring to them separately (e.g., "the smallest lesion"), they would be separate specimens. As such, a separate evaluation and diagnosis would be required for each, and each would be separately noted in the text of the report. In such a case, 88305 would be reported more than once. |
