Pathology/Lab Coding Alert

Knowing the organ name is not enough. Although reporting head and neck tissue examination with codes 88300-88309 appears simple just find the specimen in the list under each code looks can be deceiving.
 
To ensure payment for the pathologists services, you also have to know if the tissue represents a biopsy or an excision. In some cases, you have to know whether a resection is for tumor or if the specimen includes lymph nodes.
 
Several head and neck organs appear under multiple codes for surgical pathology, says R.M. Stainton, MD, president of Doctors Anatomic Pathology in Jonesboro, Ark. For example, salivary gland, with various modifying terms, is a listed specimen under 88305 and 88307. You have to understand the modifying terms that determine the level of service for a particular organ or tissue type, Stainton says.
 
Use the following list to ensure that you report neck specimens to the appropriate surgical pathology level.
 CPT 88304 Level III Surgical pathology, gross and microscopic examination
Tonsil and/or adenoids

 88305 Level IV Surgical pathology, gross and microscopic examination
Larynx, biopsy
Nasopharyns/oropharynx, biopsy
Parathyroid gland
Salivary gland, biopsy
Tongue, biopsy
Tonsil, biopsy
Trachea, biopsy

 88307 Level V Surgical pathology, gross and microscopic examination
Larynx, partial/total resection
Lymph nodes, regional resection
Salivary gland
Thyroid, total/lobe

 88309 Level VI Surgical pathology, gross and microscopic examination
Esophagus, partial/total resection
Larynx, partial/total resection with regional lymph nodes
Tongue/tonsil resection for tumor