Pathology/Lab Coding Alert

Question: Our pathologist received three large uterine masses and diagnosed each as a fibroid tumor. How should we code this?
Florida Subscriber

Answer: The correct code for a pathology exam of fibroid tumor is 88305 (Level IV -quot; Surgical pathology, gross and microscopic examination, leiomyoma[s], uterine myomectomy -quot; without uterus). You-ll notice that the code involves -leiomyoma(s),- indicating that you should report the code once whether the pathologist examines one or multiple fibroids as a single specimen. Only in the rare case that a surgeon separately identifies and submits distinct tumors for separate diagnosis should you report more than one unit of 88305.
 Uterus absence is key: You should use 88305 only for myomectomy specimens -quot; that is, fibroid tumors that the surgeon removes while leaving the uterus intact. Although the surgeon may perform a myomectomy for patients of childbearing age who have fibroid tumors, the much more common procedure for leiomyoma is a hysterectomy. If the specimen you receive is fibroid tumors with the uterus, you should not use 88305.
 Do this: Instead, you should code the uterus with leiomyomas as 88307 (Level V -quot; Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, other than neoplastic/prolapse).
 Exception alert: Although ICD-9 classifies leiomyoma as a benign neoplasm, coding convention supported by the American Medical Association and the College of American Pathologists dictates that you code this condition as 88307, not 88309 (Level VI -quot; Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, neoplastic).