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Question: Our pathologist received a specimen that the op report identified as “soft tissue mass, right side of the neck.” The pathologist processed the specimen in two cassettes, and upon microscopic examination, identified the mass as a lipoma. What are the correct procedure and diagnosis codes for this case?

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Answer: This is a case that demonstrates an important principle about coding surgical pathology procedures — always wait for the diagnosis before assigning the procedure code.

Here’s why: If you had assigned the procedure code prior to the pathologist’s diagnosis, you would have inappropriately assigned 88307 (Level V - Surgical pathology, gross and microscopic examination … soft tissue mass (except lipoma) -biopsy/simple excision …) to accompany a nonspecific diagnosis code for a soft tissue mass of the neck, such as R22.1 (Localized swelling, mass and lump, neck). Note that the descriptor language for 88307 specifically states you cannot use the code for a lipoma.

However, after the pathologist issues their final diagnosis, the coding changes completely. You will assign a definitive diagnosis code for the lipoma, which would be D17.0 (Benign lipomatous neoplasm of skin and subcutaneous tissue of head, face and neck). That then leads you to assign the correct procedure code, which in this case would be 88304 (Level III - Surgical pathology, gross and microscopic examination… Soft tissue, lipoma …). Again, the descriptor language for 88304 specifically states this is the correct code for a lipoma diagnosis.

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