Pathology/Lab Coding Alert

Question: Our pathologist received tissue from a breast case in two separate containers — one labeled “quadrantectomy, left lower inner quadrant” and one labeled “left axillary lymph nodes.” I’ve been instructed that breast and lymph nodes are bundled, but I’d appreciate advice on how to bill this case.

Utah Subscriber

Answer: When coding pathology examination of a total mastectomy specimen, you are correct that you should bundle the axillary lymph nodes, even if the pathologist receives the tissue in separate containers. For a total mastectomy, you would code the case as 88309 (Level VI - Surgical pathology, gross and microscopic examination … Breast, mastectomy - with regional lymph nodes …). You can see that the code definition includes the lymph nodes, which is why they’re bundled, even if separately submitted.

But the case you describe is not a total mastectomy. Instead, a quadrantectomy is a partial mastectomy, and you should code that as 88307 (Level V - Surgical pathology, gross and microscopic examination, … Breast, mastectomy - partial/simple …). Pathologists often receive a partial mastectomy specimen without any lymph nodes, and the CPT^® code descriptor and coding convention do not require you to bundle lymph nodes with an 88307 breast specimen.

Because the pathologist in this case separately receives and examines axillary lymph nodes, you should report a separate code for that service, which is another unit of 88307 (… Lymph nodes, regional resection …).