Pathology/Lab Coding Alert

Question: When submitting multiple pieces from a bone specimen, how do we bill professional services for decalcification? Do we bill multiples of CPT 88311 based on the number of blocks submitted or only one code per accession?

Imad Almanaseer, MD
Park Ridge, Ill.

Answer: When coding for pathology services, it is important to remember that, according to the CPT manual, a specimen is defined as tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis. In your example, you indicate that the multiple pieces represent a single specimen, a single accession. As such, the surgical pathology code would be assigned depending on the type of specimen (e.g., 88307 [level V surgical pathology, gross and microscopic examination, bone fragment(s), pathologic fracture]).

Code 88311 (decalcification procedure [list separately in addition to code for surgical pathology examination]) is an add-on code for surgical pathology. That means it is reported in addition to the surgical pathology code for the specimen. However, the unit of service for the add-on codes is still the specimen. Therefore, you would report 88311 only once per specimen, regardless of the number of blocks.