Pathology/Lab Coding Alert
Endometrial Carcinoma
Anonymous Wisconsin Subscriber
Answer: From the information you have given, you would not code them separately. The ovaries and tubes usually are removed incidentally to the endometrial carcinoma and therefore would be bundled under the code 88309 (uterus with or without tubes and ovaries, neoplastic). It appears that this is true in your case: that the procedure was carried out for endometrial carcinoma, and the cyst was discovered incidentally.
There may be some circumstances that warrant considering ovaries and uterus as separate specimens, but these would need to be clearly documented in the medical record. For example, if a neoplastic ovary resection is examined (88307, ovary, with or without tube, neoplastic), and the uterus is sent as a separate specimen to be examined for suspected involvement of neoplasm, then it could be coded separately, based on the level of service (88307 or 88309). This is another example of the need for accurate, complete documentation in the medical record.
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Question: My question involves a specimen of uterus with tubes and ovaries. The diagnosis is [...]
