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Pathology/Lab Coding Alert

Reader Question:

Don't Assume Special Stain

Published on Mon Aug 06, 2012

Question: Our pathologist evaluates a stomach resection from a sleeve gastrectomy performed for morbid obesity. I know the specimen exam is 88307, but I've been told that I should also always add 88342 with gastric specimens for an H. pylori stain -- is this correct?Georgia SubscriberAnswer: You should report only what the pathologist's documentation supports. You are correct that a sleeve gastrectomy specimen exam warrants 88307 (Level V -- Surgical pathology, gross and microscopic examination, Stomach - subtotal/total resection, other than for tumor), in most cases.Caution: A sleeve gastrectomy for treating morbid obesity generally involves removing a significant portion of the stomach, but if your pathologist receives an unusually small specimen, you might consider 88305 (Level IV - Surgical pathology, gross and microscopic examination, Stomach, biopsy).The pathologist might also examine special stains to test for Helicobacter pylori. Although this is common for gastric specimens, you should not code for a special stain [...]
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