Pathology/Lab Coding Alert

Question: The surgeon submitted a lesion excision from the right thigh that extended beyond layers of skin to include subcutaneous soft tissue and even some muscle. The pathologist diagnosed melanoma. Should we code this as an 88307 since the specimen was more than skin?

Virginia Subscriber

Answer: No, you should not report this specimen exam as 88307 (Level V -- Surgical pathology, gross and microscopic examination, soft tissue mass [except lipoma] -- biopsy, simple excision).

Here's why: Even if you have a very deep excision into the subcutaneous tissue, you should not code for a soft tissue mass when the pathology diagnosis confirms a skin condition.

Because the pathologist diagnosed melanoma (172.7, Malignant melanoma of skin, lower limb, including hip), you know that the specimen is skin, not a soft tissue mass.

The correct code for the pathologist's service is 88305 (Level IV -- Surgical pathology, gross and microscopic examination, skin, other than cyst/tag/ debridement/plastic repair).

You can report 88307 for a specimen that includes skin and associated subcutaneous tissue only if the pathology report and the ICD-9 diagnosis code document that the specimen is a soft tissue mass/tumor, not a skin specimen.