Pathology/Lab Coding Alert

CPT 88309 is just the beginning

For a pathologist's radical prostatectomy examination, you might report a single code (88309, Level VI - surgical pathology, gross and microscopic examination, prostate, radical resection), or you might report several other codes in addition to 88309. How you report the service depends on several factors -- like bundling rules, how the surgeon submits the resected tissue, and what the pathologist does with it. 1. Choose the Correct Surgical Pathology Level

First you have to find "prostate" out of the approximately 180 listed specimens under CPT surgical pathology codes 88302-88309. Once you see that CPT includes prostate four times, as shown in the following list, you'll have to pick the right code based on the type of prostate tissue.

88305 -- Level IV - surgical pathology, gross and microscopic examination, prostate, needle biopsy
88305 -- Level IV - surgical pathology, gross and microscopic examination, prostate, TUR
88307 -- Level V - surgical pathology, gross and microscopic examination, prostate, except radical resection
88309 -- Level VI - surgical pathology, gross and microscopic examination, prostate, radical resection.

"An 88309 radical prostate resection involves the entire prostate gland and almost always includes the attached seminal vesicles," says Stephen Yurco III, MD, partner and pathologist at Clinical Pathology Associates in Austin, Texas. The resection may also include a segment of vas deferens, fatty tissue, and the prostate/bladder neck junction.

You should report 88307 for a sub-total prostate resection that involves less tissue than a radical resection. Use 88305 for two different types of prostate tissue -- needle biopsy specimens, or portions of resected prostate tissue removed through a transurethral approach.

Requirement: Report the surgical pathology code (88305-88309) that best describes the type of prostate specimen.   2. Don't Unbundle En Bloc Prostatectomy Submission

Submitted en bloc, a radical prostatectomy that includes attached seminal vesicles, surrounding fatty tissue, and prostate/bladder neck junction fits the CPT definition of a surgical pathology specimen -- tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis. Code 88309 describes this specimen.

"As a radical resection, you'd expect to receive small amounts of other tissue attached to the prostate, and you shouldn't code them separately," Yurco says.

Although not specified by CPT, the College of American Pathologists (CAP) has advised that you should always bundle seminal vesicles with a radical prostate resection. "Seminal vesicles are part of a radical resection of the prostate and would not be separately coded, even if submitted in a [...]