General Surgery Coding Alert

Do you remember what code to use for a gross examination only?

Surgical pathology codes have lengthy descriptors that identify several specimen types, and each code represents various levels of physician work. Revenue Cycle Insider has put together a few fun questions to evaluate your knowledge of the 88300-88309 surgical pathology code range.

Put your surgical pathology coding skills to the test with this end-of-the-year coding quiz.

Question 1: What surgical pathology code will you assign for a tonsil specimen biopsy collected during a tumor resection?

You’ll assign 88309 (Level VI - Surgical pathology, gross and microscopic examination … Tongue/tonsil – resection for tumor …) to report the tonsil specimen biopsy performed during a tumor resection. In this procedure, the surgeon obtains the specimen during a resection, which is where the surgeon attempts to excise an entire lesion that is suspected of being cancerous — a larger and more complex procedure.

The Surgical Pathology code section includes two other codes that reference procedures performed on the tonsils:

• 88304 (Level III - Surgical pathology, gross and microscopic examination … Tonsil and/or adenoids …)
• 88305 (Level IV - Surgical pathology, gross and microscopic examination … Tonsil, biopsy …)

Use 88304 when your lab obtains the specimen from a tonsillectomy procedure that the surgeon performs for a reason other than suspected cancer, such as tonsillitis. On the other hand, assign 88305 when the surgeon suspects the tonsil may be cancerous. Neither of these examples for 88304 and 88305 match the procedure presented in the question.

Question 2: A surgeon performed an esophagogastroduodenoscopy (EGD) and collected a duodenum biopsy. The pathologist then performed an H. pylori test on the specimen, which was positive. The provider diagnosed the patient with a peptic ulcer. What surgical pathology procedure code(s) will you assign?

Use 88305 (Level IV - Surgical pathology, gross and microscopic examination … Stomach, biopsy …) to report the pathologist’s biopsy exam. You’ll also assign 87081 (Culture, presumptive, pathogenic organisms, screening only) for the Helicobacter pylori, also known as H. pylori, test on the biopsy specimen. Labs will usually perform a campylobacter-like organism (CLO) test for a suspected H. pylori infection.

Question 3: A surgeon performed a total hip arthroplasty. The operative note states, “a left femoral head consisting of 2 bone fragments” with “articular surface … granular with extensive eburnation and osteophyte formation and attached soft tissue.” What surgical pathology code will you assign?

Report 88304 (Level III - Surgical pathology, gross and microscopic examination … Femoral head, other than fracture …) for the situation. The code selection depends on the specimen submitted, not what surgery was performed. Even though the surgeon collected the sample during a total hip arthroplasty, the pathologist only received and examined the femoral head with soft tissue attached.

Some coders may consider 88305 (Level IV - Surgical pathology, gross and microscopic examination … Joint, resection …), but this code doesn’t apply in this case. Code 88305 is designated for surgical procedures like joint resections — or hip arthroplasty — instead of just bone fragments being the submitted specimens.

Question 4: A patient presents to their primary care physician (PCP) with an abnormal growth on their external abdomen. The PCP performs a physical exam and diagnoses the patient with an inguinal hernia sac. The provider then orders a surgical procedure to repair the hernia. Will you assign 88300 or 88302 for the procedure?

Both 88300 (Level I – Surgical pathology, gross examination only) and 88302 (Level II - Surgical pathology, gross and microscopic examination … Hernia sac, any location …) are valid code options, but only one code is correct in this case.

You’ll assign 88300 to report the surgical pathology procedure of diagnosing the inguinal hernia sac. The PCP performed only a physical examination of the abnormality, which falls under the “gross examination only” portion of the descriptor. According to the CPT^® guidelines, “Service code 88300 is used for any specimen that in the opinion of the examining pathologist can be accurately diagnosed without microscopic examination.”

Code 88302’s descriptor does list “Hernia sac, any location,” but the provider didn’t use microscopic examination to confirm the diagnosis.

Question 5: A patient pregnant at 39 weeks had a cesarean section (C-section) and the surgeon also performed bilateral tubal ligation. Pathology documentation shows separate specimens for the left and right fallopian tubes along with the placenta. What surgical pathology code(s) will you assign for the procedure?

The question states that the patient underwent a C-section as well as a tubal ligation for both the left and right fallopian tubes. At 39 weeks, the patient was in their third trimester, which is when the placenta was taken during the C-section. Therefore, the pathologist obtained the patient’s fallopian tubes and the placenta as specimens.

According to the CPT^® guidelines, “levels 88302 through 88309 are specifically defined by the assigned specimens.” This means that you’ll need to assign the following two separate surgical pathology CPT^® codes for this encounter:

• 88302 (Level II - Surgical pathology, gross and microscopic examination … Fallopian tube, sterilization …)
• 88307 (Level V - Surgical pathology, gross and microscopic examination … Placenta, third trimester …)

The codes listed above specifically mention the specimens the pathologist collected and examined.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC