Pathology/Lab Coding Alert

Question: If we receive a breast quadrantectomy separately from an axillary node dissection (in two different containers), should this be coded as one specimen (88307) or two specimens (88307 x 2)?

California Subscriber

Answer: Based on the code description, the breast quadrantectomy specimen would be reported using 88307 (level V - surgical pathology, gross and microscopic examination; breast, mastectomy partial/simple). The axillary node dissection would be considered a separate specimen because it is not an integral part of a partial mastectomy. If the second specimen includes multiple nodes, report an additional 88307 (... lymph nodes, regional resection). If it is a single node, report 88305 (level IV, surgical pathology, gross and microscopic examination; lymph node, biopsy).

This coding scenario can be confusing because a radical mastectomy includes axillary lymph nodes (88309 level VI, surgical pathology, gross and microscopic examination; breast, mastectomy with regional lymph nodes) as part of the specimen. Because the breast quadrantectomy is a partial mastectomy, it would not be appropriate to report 88309 even though you also received axillary node(s).