Pathology/Lab Coding Alert

Don't code undocumented margins

Try your hand at coding breast-lesion excisions using the principles in "Zero In on Breast Specimens With Your New Best Coding Tool"

The following scenarios illustrate the salient portions of a pathology report - code each scenario yourself, then read the solution to see what our experts say. Scenario 1: Specimen Submitted: Left breast mass excision.
Gross Description: Sectioning of the black inked portion reveals a tan-white rubbery nodule 0.6 cm in the greatest dimension extending to an inked margin.
Microscopic Description: Six slides examined show breast tissue containing a well-demarcated fibroadenoma exhibiting a predominantly intracanalicular growth pattern.
Diagnosis: Breast fibroadenoma.
 
Solution 1: 88305. Although the surgeon inked the margins, the pathologist did not document margin evaluation because the benign findings of a discrete lesion did not require a margin exam. Scenario 2: Specimen Submitted: Lesion excision, left breast.
Gross Description: The margins are inked as follows: lateral is yellow, medial is orange, superior is black, deep is green, and inferior is blue.
Microscopic Description: The tumor cells show moderate to focal severe atypia. Occasional mitoses are seen. Tumor is present within 1.0 mm from blue inked margin. No invasive tumor is seen.
Diagnosis: Left breast lesion excision: Lobular carcinoma in situ (LCIS) is 1.0 mm from inferior superficial margin.  
 
Solution 2: CPT 88307 . The pathologist mentions proximity of tumor to margins in both the microscopic and diagnosis sections, providing documentation for the higher code. The diagnosis of LCIS, although not invasive, is potentially malignant and therefore requires a margin exam. Scenario 3: Specimen Submitted: Right breast excisional biopsy.
Gross Description: All margins inked black. Tumor size: None grossly recognized.
Microscopic Description: 10 blocks, 10 slides examined.
Diagnosis: Breast, right, excisional biopsy: Infiltrating carcinoma with lobular ductal and focal signet ring cell features (estimated aggregate size of 1.2 cm). 
 
Solution 3: 88305. Given the malignancy diagnosis, the pathologist should have performed and documented a margin exam, which would earn an 88307. Absent that documentation, however, you can only support coding 88305. 

Stephen Yurco III, MD, partner and pathologist at Clinical Pathology Associates in Austin, Texas, helped prepare these solutions.