Pathology/Lab Coding Alert

Question: The pathologist examined frozen sections and a skin biopsy that he diagnosed as melanoma, margins not clear. The surgeon re-excised the lesion with wide margins and submitted that specimen later the same day. How should we code this scenario?

New York Subscriber

Answer: Report the frozen section exam as 88331 (Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen). Because the surgeon submitted one lesion excision, then later submitted the re-excision, the pathologist should report 88305 x 2 (Level IV -- surgical pathology, gross and microscopic examination, skin, other than cyst/tag/debridement/plastic repair) once for each of the two specimens.
 
Don't miss: No matter how large or complicated the pathologist finds the melanoma re-excision with wide margins, the specimen still warrants only 88305. Reporting a higher service level such as 88307 (Level V -- surgical pathology, gross and microscopic examination) based on the increased work for the complex skin specimen is tempting but wrong. Using 88307 or higher for a skin specimen is upcoding.