Pathology/Lab Coding Alert

Don't miss the 88305/88307 distinction

Some breast coding is easy - but there's a gray area at the margins that leaves many coders scratching their heads. And missing the margins could cost your practice $80 every time.

The table above is your foolproof tool to sift through the confusing terminology and pinpoint the correct code for each specimen type. If you find one of the surgical terms - such as simple mastectomy, lumpectomy or needle-core biopsy - in your pathology report, you should be home free in choosing the proper code.

Warning: Even if you see "excision of lesion" terminology, you should only use CPT 88307 (Level V - Surgical pathology) if the pathologist examines and documents surgical margins. "We sometimes have difficulty making the appropriate code selection between 88305 (Level IV - Surgical pathology) and 88307 when the pathology report does not clearly state that the pathologist evaluated margins for a breast specimen," says Sally Trulson, CPC, lead certified coder for Pathology Diagnostic Specialists LLC in San Diego.

Focus on Margin Documentation

Ensuring proper payment for an 88307 breast-lesion exam is easy - the pathologist just has to mention the margin exam. "At the very least, the pathology report should include a simple statement such as 'Margins clear,' to indicate the evaluation service," says Stephen Yurco III, MD, partner and pathologist at Clinical Pathology Associates in Austin, Texas.

Audit-proof your breast exam coding by making sure you have proper documentation. Don't report 88307 for breast excisions based on the following misconceptions:

Myth 1: If the gross statement indicates inked margins, you can assume the pathologist performed a margin evaluation and report 88307.

Reality 1: The diagnosis or microscopic statement should mention the margin evaluation. "The pathologist should document whether the margins are involved or clear to justify coding 88307," Yurco says. Claiming 88307 based on only a gross statement of inked margins is risky coding.

Myth 2: If the excised-lesion diagnosis is benign, report 88305; if the diagnosis is malignant, use 88307.

Reality 2: Although pathologists typically evaluate margins for excised malignant lesions and often don't do so for excised benign lesions, that's not always the case. As the College of American Pathologists stated in the June 2003 CAP Today, "The final diagnosis is not the sole determining factor in assigning the appropriate CPT code for breast excisions ."

Rather, the key is a pathology report documenting that a margin evaluation is required and completed. "Our practice has established that an excised breast malignancy, atypia, or re-excision requires margin evaluation, and our pathologists document those findings," Yurco says. "When we have clearly benign findings for a discrete lesion, we don't usually perform or document a margin exam, even if the surgeon has oriented the specimen with inked margins," he says.