Pathology/Lab Coding Alert

Question: We have Ob/Gyn clients who are asking for the weight of uterine specimens apart from the tubes and ovaries. Why is this important, and should our pathologists separate the uterus, tubes, and ovaries for the exam?

Washington Subscriber

Answer: CPT distinguishes several surgical codes for uterine specimens based on the weight of the organ.

For instance, CPT provides surgical codes for vaginal hysterectomy based on the mass as follows:

- 58260 -- Vaginal hysterectomy, for uterus 250 g or less;

- 58262 -- - with removal of tube(s) and/or ovary(s)

- 58290 -- Vaginal hysterectomy, for uterus greater than 250 g;

- 58291 -- - with removal of tube(s) and/or ovary(s).

Based on the surgical approach and uterine portion removed, CPT makes the same weight distinction for three other sets of codes with or without removal of tube(s) and/or ovary(s) (58451-58544, 58550-58554, and 58570-58573).

You can see that the weight the surgeon uses to select the code does not include the tubes and ovaries. Although these parts do not usually weigh much (unless the patient had nodules and cysts), their presence in the specimen can impact billing if the weight is close to 250 g.

Although as a courtesy your pathologist may separate the uterus, tubes, and ovaries for weight purposes, you should not unbundle the specimen for pathology billing. That means you still select the appropriate code from the following list:

- 88305 -- Level IV - Surgical pathology, gross and microscopic examination; uterus, with or without tubes and ovaries, for prolapse

- 88307 -- Level V - Surgical pathology, gross and microscopic examination; uterus, with or without tubes and ovaries, other than neoplastic/prolapse

- 88309 -- Level VI - Surgical pathology, gross and microscopic examination; uterus, with or without tubes and ovaries, neoplastic.