Pathology/Lab Coding Alert

Answer: You should not code this procedure as a soft tissue mass exam using 88307 (Level V - Surgical pathology, gross and microscopic examination … Soft tissue mass (except lipoma) - biopsy/simple excision …).

Here’s why: Epidermoid cysts arise in the skin, so the pathologist’s statement definitively indicates that the specimen is skin, even if you’re unclear about the final diagnosis. That means you should not use 88307 because the specimen is not soft tissue. The pathologist’s statement leads to code 88304 (Level III - Surgical pathology, gross and microscopic examination … Skin - cyst/tag/debridement …).

Dx: For outpatient services, ICD-10-CM Official Guidelines, Section IV.G, states, “Do not code diagnoses documented as ‘probable, ’ ‘suspected,’ ‘questionable,’ ‘rule out,’ ‘compatible with, ’ ‘consistent with, ’ or ‘working diagnosis’ or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”

Effective Oct. 1, 2019, an update to the guidelines added “compatible with” and “consistent with” to the list of terms that indicate uncertain diagnosis. Pathologists should no longer use those terms when stating a final, definitive diagnosis.

Do this: Your responsibility as a coder is to assign the correct codes based on the words in the provider’s report. Based on what you’ve included in your question, you should not report the case as L72.0 (Epidermal cyst). Instead, you should turn to R22.1 (Localized swelling, mass and lump, neck). Alternatively, you may consult the pathologist for clarification — and possibly a discussion about documentation.