Pathology/Lab Coding Alert

Question: We received a labeled right axillary mass, which consists of an 8.5-by-4.0-cm elliptical strip of tan skin, overlying 4 cm of subcutaneous soft lobulated fatty tissue. Central, the skin surface bulges, and upon sectioning, the subcutaneous tissue is yellow-tan, lobulated, soft and glistening. Centrally, within the subcutaneous fat is a 0.9-by-0.6-cm discrete tan firm movable nodule. No stromal clefts or cysts are grossly discernible. This lesion is located at least 1.2 cm from the nearest transverse soft tissue resection margin. The diagnosis is fibroadenoma, right axillary biopsy; incidental breast tissue with focal mild non-proliferative cystic change; incidental mild hidradenitis. How should I code this?

Karen Branch
Inter-Mountain Pathology Associates, PC, Bristol, Tenn.

Answer: The specimen would be coded 88305 (level IV surgical pathology, gross and microscopic examination; breast, biopsy, not requiring microscopic evaluation of surgical margins). The logic of CPT surgical pathology codes is specimen driven and, in the case of breast excisions, depends on the need for evaluation of surgical margins.

This example would not fit code 88307, which describes a breast specimen involving work similar to a partial or simple mastectomy. Breast specimens not requiring microscopic examination of margins, such as incisional or needle biopsies, or excisions of discrete lesions such as fibroadenoma, should be reported with code 88305.