Pathology/Lab Coding Alert

Question: When our pathologist receives a breast lesion, the surgeon sometimes identifies the specimen as a percutaneous needle core biopsy, and sometimes as an open incisional biopsy. Does this make a difference in how we should code the pathologist's work?


Indiana Subscriber
Answer: Although this information makes a difference for the surgeon's coding, it does not necessarily make a difference for the pathologist's coding.

The surgeon has to choose between codes such as 19100 (Biopsy of breast; percutaneous, needle core, not using imaging guidance [separate procedure]) or 19101 (... open incisional).

But the pathologist has to distinguish a breast specimen based not on how the surgeon acquired it, but based on the extent of the pathology exam. Specifically, the crucial information for a breast lesion is whether the pathologist must examine surgical margins.

The two choices are:

 88305 - Level IV - Surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins

 88307 - Level V - Surgical pathology, gross and microscopic examination, breast, excision of lesion, requiring microscopic evaluation of surgical margins. To select the proper code, you'll have to see what the pathology report documents. If the pathologist identifies and diagnoses surgical margins, use 88307. If not, use 88305. Although the pathologist does not typically evaluate margins for a needle core biopsy, and is more likely to evaluate margins from an open incisional biopsy in which the surgeon attempts to remove an entire small lesion, you cannot rely on this distinction to select the proper pathology code. Only the pathologist's documented work can help you distinguish between these two codes.