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Pathology/Lab Coding Alert

Reader Question:

Use 88300 for Gross Only

Published on Tue Sep 23, 2003

Question: Suppose the lab accessions a breast biopsy specimen, providing a gross description dictation and preparing a block and slides. If the pathologist then determines that there is insufficient material on the slides to examine and interpret, how should we code the service? Massachusetts Subscriber Answer: Report the gross examination as 88300 (Level I - surgical pathology, gross examination only). Do not report the microscopic examination (88305, Level IV - surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins) if the pathologist was unable to complete the service due to insufficient cells.  
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