Pathology/Lab Coding Alert

Question: How should I code the procedure based on the following pathology report: From right shoulder, a gray-white segment of bony tissue measuring 6.3 cm x 5.9 cm x 2.6 cm; submitted representative sections in two cassettes following decalcification. Final diagnosis: cartilage-capped bone with fibrosis. Is the procedure code times two since there are two cassettes?


North Carolina Subscriber


Answer: No, you should not report the procedure code times two for two cassettes. The unit of service for surgical pathology codes is the specimen, which in this case is the bone fragment.

You should code based on the specimen, regardless of the number of cassettes or slides involved in the examination.

Because the report describes a non-pathologic bone fragment, the correct code for the pathologist's exam is 88304 (Level III--Surgical pathology, gross and microscopic examination, bone fragment[s], other than pathologic fracture).

You should also report the decalcification as a separate procedure using +88311 (Decalcification procedure [list separately in addition to code for surgical pathology examination]).