Pathology/Lab Coding Alert

Question: Our pathologist received a hemithyroidectomy specimen with a request for frozen-section intraoperative consultation to be followed later by anatomic pathology exam. Based on the intraoperative consult report, the surgeon then removed the other thyroid lobe. How should we code the case?

Ohio Subscriber

Answer: You should report the intraoperative consultation using a code such as 88331 (Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen). You don’t provide details regarding whether the pathologist looked at additional tissue blocks, so you shouldn’t report +88332 (… each additional tissue block with frozen section(s) (List separately in addition to code for primary procedure) without documentation.

Specimen number: One big question for this case is whether to code the hemithyroidectomies as two separate pathology examination procedures, or as a single thyroidectomy exam procedure. The ambiguity comes from the code definition (88307, Level V - Surgical pathology, gross and microscopic examination … Thyroid, total/lobe …), which assigns the same code to a total or lobe thyroid resection.

Timing is key: Because the surgeon submits each hemithyroidectomy at a different time, each for separate examination and evaluation, the pathologist will perform two distinct anatomic pathology procedures. With documentation of the two separate specimens, you should code 88307 x 2 for the case.

Watch modifier: Some payers may prefer that you list the two codes with a modifier, such as 59 (Distinct procedural service) or related modifiers X {ESPU} (Separate … Encounter …Structure … Practitioner … Unusual non-overlapping service…). Medicare typically reserves these modifiers to override edit pairs of different codes based on National Correct Coding Initiative (NCCI) edits, but some payers my require one of these modifiers to document multiple units of a single procedure.

Caution: If the pathology report treats the two lobes as one specimen and provides one diagnosis, you should not distinguish the lobes for coding purposes.