Revenue Cycle Insider

Question: We are seeing denials when 88305 is billed with certain diagnosis codes, so I’m trying to put together a credible list of payable codes. For example, 88305 is being denied with R31.0. Is this because the biopsy needs to be on a neoplasm or some sort of growth diagnosis?

AAPC Forum Participant

Answer: You are correct. CPT^Ò 88305 (Level IV - Surgical pathology, gross and microscopic examination …) is primarily used for body tissue biopsies to diagnose malignancies and inflammatory conditions. As such, it is unlikely that R31.0 (Gross hematuria) would be an acceptable diagnosis code for this kind of biopsy.

As for a list of payable diagnosis codes, Horizon Blue Cross Blue Shield of New Jersey offers a useful, though not exhaustive, list of diagnoses in its policy document, “Daily Maximum Units for Surgical Pathology and Microscopic Examination.”

For prostate conditions, for example, you might consider the following:

• C61 (Malignant neoplasm of prostate)
• D29.1 (Benign neoplasm of prostate)
• D07.5 (Carcinoma in situ of prostate)
• D40.0 (Neoplasm of uncertain behavior of prostate)
• N40.- (Benign prostatic hyperplasia)
• N41.- (Inflammatory diseases of prostate)
• N42.- (Other and unspecified disorders of prostate)

And for gastrointestinal conditions, a payer might find the following codes to be acceptable:

• C18.- (Malignant neoplasm of colon)
• D12.- (Benign neoplasm of colon, rectum, anus and anal canal)
• K63.5 (Polyp of colon)
• K51.00 (Ulcerative (chronic) pancolitis without complications)
• K51.919 (Ulcerative colitis, unspecified with unspecified complications)
• K29.5- (Unspecified chronic gastritis).

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC