Pathology/Lab Coding Alert

Question: We received a single container with two breast biopsies from the left breast, one marked with a suture. The surgical report identified the sutured tissue "with microcalcifications" and the other "without microcalcifications." Should we report this as one breast biopsy or two? 

Colorado Subscriber

Answer: The unit of service for surgical pathology is the specimen, not the container. Because the surgeon identified two distinct biopsy specimens, the pathologist should examine them separately and report a separate diagnosis for each.
 
You should report two units of 88305 (Level IV - Surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins), one for each biopsy.
 
If the specimens were actually excisions of two distinct lesions requiring margin evaluations, you would report two units of 88307 (Level V - Surgical pathology, gross and microscopic examination, breast, excision of lesion, requiring microscopic evaluation of surgical margins).