Pathology/Lab Coding Alert

Question: Sometimes the surgeon submits a breast lumpectomy specimen while the patient is in surgery, and upon gross findings of tumor near the margin, the surgeon samples additional margins. The pathologist receives the lumpectomy (primary specimen) and three separately identified margins. How should you code this?

New York Subscriber

Answer: You should code the case based on the pathology report. The first charge you should make is for the service the pathologist provides when he consults during surgery and states, based on gross findings, that the margin is not clear. You should report that service as 88329 (Pathology consultation during surgery).

Because the pathologist grossly determines that the lumpectomy margins are not clear, he might not perform (and note in the pathology report) microscopic margin evaluation. If that is the case, you should code the lumpectomy as 88305 (Level IV -- Surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins).

Additionally, the pathologist should bill for each separately identified surgical margin -- three in this case. CPT does not list "surgical margin" as a specimen, so you'll have to select the code from the range 88302-

88309 (Level II to VI -- Surgical pathology, gross and microscopic examination ...). Select the proper code based on the level of physician work (as compared to other specimens in that level).

Pathologists typically consider a straightforward surgical margin evaluation to require the level of work involved in other 88305 specimens. If that is your pathologist's determination, you should report three units of 88305 for the margins.

Bottom line: You would code this case as 88329 and 88305 x 4.