Pathology/Lab Coding Alert

Question: Our pathologist received three vials from transbronchial needle biopsies for a patient with a large lesion near the surface of the upper lobe of the right lung. The surgeon labeled each vial, designating the specific location it was taken from. Should we report each vial separately, or should we bill for one lung needle biopsy? Tennessee Subscriber Answer: Because the surgeon separately identified and submitted three lung needle biopsies from separate sites, you should report three units of 88305 (Level IV - surgical pathology, gross and microscopic examination, lung, transbronchial biopsy). Each biopsy represents a separate specimen, requiring individual examination and diagnosis. The pathology report should show a diagnosis for each specimen. Not only does this provide the information the surgeon requested, but the report also provides documentation necessary to support coding CPT 88305 x 3. - Reader Questions and You Be the Coder were prepared with the assistance of R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.