Pathology/Lab Coding Alert

Question: How should we code the evaluation of breast tissue removed for breast-reduction surgery? We've been told by a plastic surgeon that others perform only a gross examination for cosmetic surgery, but we perform sections and micro as well. We've also been told that we should "discount" the service for cosmetic surgery. California Subscriber

Answer: Reduction mammoplasty is a listed specimen in surgical pathology, so you should report it with the listed code. The correct code for examination of breast-reduction tissue is 88305 (Level IV Surgical pathology, gross and microscopic examination, breast, reduction mammoplasty). Performing gross and microscopic examination for this tissue is the standard of care; gross only for reduction mammoplasty is not. "Discounting" the pathology examination of this tissue is also inappropriate. You will notice that the reduction mammoplasty is already an 88305, similar to a breast biopsy not requiring margin evaluation, rather than an 88307 (Level V Surgical pathology, gross and microscopic examination), similar to a partial mastectomy. Reader Questions and You Be the Coder were prepared with the assistance of R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.