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Pathology/Lab Coding Alert

Reader Question:

Identify Femoral Head Specimen

Published on Tue Jul 01, 2003

Question: How should we report the examination of a femoral head submitted for avascular necrosis? Florida Subscriber Answer: Although CPT lists eight bone specimens under surgical pathology codes 88304-88309, you should report the most specific code available to describe the specimen. CPT lists two femoral head specimens in this section: 88304 (Level III Surgical pathology, gross and microscopic examination, femoral head, other than fracture) and 88305 (Level IV Surgical pathology, gross and microscopic examination, femoral head, fracture). Because the surgeon did not submit the femoral head for fracture, you should report the examination for avascular necrosis as 88304.

The pathologist typically performs a decalcification procedure with this bone exam as well. If the lab performs and documents a decalcification, report add-on code +88311 (Decalcification procedure [list separately in addition to code for surgical pathology examination]) in addition to the 88304.  
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