Pathology/Lab Coding Alert

Question: Our pathologist examined a spleen specimen with attached splenic nodes. I noticed that some specimens listed in CPT^® state that lymph nodes are included, but that’s not the case for spleen. Can I separately report a lymph node resection?

New Hampshire Subscriber

Answer: No, you should not separately report attached splenic lymph nodes with a spleen specimen. The appropriate coding for the service you describe is 88305 (Level IV - Surgical pathology, gross and microscopic examination … Spleen …).

You are correct that certain specimens specifically include attached lymph nodes in the CPT^® definition, such as 88309 (Level VI - Surgical pathology, gross and microscopic examination … Breast, mastectomy - with regional lymph nodes …). But those aren’t the only specimens that might typically include attached lymph nodes that you should bundle.

General rule: You should not unbundle attached lymph nodes for billing purposes if the primary specimen ordinarily comes with attached lymph nodes. The following specimens and attached lymph nodes often follow this convention: