Pathology/Lab Coding Alert

Question: When the pathologist examines a hysterectomy specimen for fibroids, should we code the case as a neoplastic uterus? I understand that fibroids are a benign neoplasm.

Arkansas Subscriber

Answer: You are correct that fibroids are a benign neoplasm. ICD-9 defines uterine leiomyoma (218) as a -benign tumor- and states that the category includes uterine fibroids, fibromyoma and myoma.

That being said, you would expect to code the pathology exam of a hysterectomy with fibroid tumors as 88309 (Level VI -- Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, neoplastic).
 
But uterine leiomyomas represent an -unwritten- exception among listed specimens in the CPT surgical pathology section. Several sources concur on this point:

The AMA in the December 2003 CPT Assistant states that -leiomyomas do not require the same degree of evaluation as other uterine neoplasms,- and therefore concludes that when leiomyoma of the uterus is the principal diagnosis for a hysterectomy specimen, you should report 88307 (Level V -- Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, other than neoplastic/prolapse) rather than 88309.

The College of American Pathologists has also published coding advice indicating that you should use 88307 for uterine leiomyoma in addition to non-neoplastic uterine conditions (CAP Today July 1999)

Exception: When the pathologist examines a myomectomy specimen, which is a resection that involves removing fibroids from the uterus without performing a complete hysterectomy, don't use 88307. CPT lists this specimen as 88305 (Level IV -- Surgical pathology, gross and microscopic examination, leiomyoma[s], uterine myomectomy ---without uterus).