Pathology/Lab Coding Alert

Question: We received a specimen identified as tonsils, soft palate and uvula. I know that the tonsil specimen would be coded 88304. But what is the correct code to use for the soft palate and uvula? Would this be bundled with the code for the tonsils?

Cathy Neal
Union City, Tenn.

Answer: The correct coding for this scenario would depend on the surgical notes and markings of the tissue, which is not clear from your description. Surgeons often remove the tonsils along with the uvula and soft palate for the treatment of sleep apnea. Typically in these cases, the two tonsils would be submitted together, and the uvula and soft palate submitted together as a specimen separate from the tonsils, for individual examination and diagnosis. In that case, the tonsils would be reported as 88304 (level III surgical pathology, gross and microscopic examination; tonsil and/or adenoids), as you mentioned.

Because the uvula and attached soft palate is an unlisted specimen, it should be assigned a code based on the level of work involved to evaluate the specimen, relative to the other specimens listed in CPT. This would probably be another 88304, similar to the tonsils. In that case, you would code 88304 X 2 on the HCFA 1500 form.

Answers to the Reader Questions and You Be the Coder are provided by R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services, an independent pathology laboratory in Jonesboro, Ark.