Pathology/Lab Coding Alert

Question: We sometimes have pathology reports for hysterectomy with a pre-op diagnosis of uterine prolapse. If the pathologist's findings indicate other pathology, such as leiomyomas or adenomas, should we report 88305 for the prolapse, or choose a different procedure code based on the pathologist's findings?Florida SubscriberAnswer: You should base the code for the pathologist's work on the findings, if available at the time of billing, rather than the pre-operative diagnosis. That means you should not bill a hysterectomy using 88305 (Level IV -- Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, for prolapse) if the pathologist diagnoses additional pathology, even if the pre-op diagnosis is "prolapse." Do this: For neoplastic findings, such as adenocarcinoma (179, Malignant neoplasm of uterus, part unspecified), report the pathologist's work as 88309 (Level VI -- Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, neoplastic).For other uterine pathology, [...]