Code This Lab by Specimen, Not Procedure
Question: I am trying to figure out the correct CPT® code for this specimen. The gross description states, “a right femoral head consisting of 2 bone fragments” with “articular surface … granular with extensive eburnation and osteophyte formation and attached soft tissue.” But the final diagnosis reads “a right femoral head, total hip arthroplasty, regenerative changes consistent with osteoarthritis, with no malignancy identified.” Given this, should I use 88305 as the report states “total hip arthroplasty,” which qualifies this as a “joint resection?” Or should I use 88304, as the submitted specimen is listed as primarily bone and the report does not provide documentation of the majority of tissues that compose a joint? AAPC Forum Participant Answer: Based on the information you provide, 88304 (Level III - Surgical pathology, gross and microscopic examination … Femoral head, other than fracture …) applies in this situation. That’s because coding is based on the specimen submitted and not the surgery performed. Despite the sample being obtained from total hip arthroplasty surgery, the pathologist only received and examined a femoral head (bone with degenerative changes) with incidental soft tissue and without a significant portion of the neck. The articular surface and osteophytes also confirm bone, and multiple joint tissues are not present. This means 88305 (Level IV - Surgical pathology, gross and microscopic examination… Joint, resection…) would not apply as the lab designated by 88305 focuses on surgical procedures such as joint resections (the total hip arthroplasty) rather than the bone fragments provided as specimens. Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
