Pathology/Lab Coding Alert

Question: How should we report two prostate needle biopsies from the same patient when one demonstrates PIN I and the other is malignant? We've been told that the code for these biopsies states "single or multiple." What is the correct diagnosis code? Wisconsin Subscriber Answer: The procedure code for pathology examination of a prostate biopsy is not dependent on the diagnostic findings. According to CPT guidelines for surgical pathology, you should code separately each specimen that involves individual accessioning, examination and reporting. In your case, report each of the two prostate biopsy examinations as 88305 (Level IV Surgical pathology, gross and microscopic examination, prostate, needle biopsy).

The surgical code for the removal of these biopsies includes the language "single or multiple" (55700, Biopsy, prostate; needle or punch, single or multiple, any approach). The surgical procedure does not necessarily coincide with the pathology specimen you need to code according to the surgical pathology guidelines.

As for the diagnosis, the pathology report should state the results for each biopsy examination. The ICD-9 code for prostatic intraepithelial neoplasm (PIN) 1 specimen is 602.3 (Dysplasia of prostate). Report the neoplasm according to the behavior, such as, 185 (Malignant neoplasm of prostate) or 233.4 (Carcinoma in situ of prostate). It is up to the primary physician to assign the patient's final diagnosis on the basis of lab and clinical findings.