Pathology/Lab Coding Alert

Question: Our pathologist received a right salpingo-oophorectomy specimen and identifies an endometrial cyst containing endometrial implantation in the ovary. The pathologist notes that the fallopian tube is unremarkable. How should we code this?

Ohio Subscriber

Answer: Report the pathologist’s exam of the right salpingo-oophorectomy specimen as 88305 (Level IV - Surgical pathology, gross and microscopic examination … Ovary with or without tube, non-neoplastic …).

Caution: You should not separately bill for the fallopian tube even though the pathologist mentions it incidentally in the report. Although CPT^® provides a separate code for fallopian tube (88305 … fallopian tube, biopsy …), the ovary code states, “with or without tube,” so you should bundle the fallopian tube as part of the ovary specimen.

Diagnosis is key: The endometrial cyst is N80.1 (Endometriosis of ovary). Don’t confuse endometrial cyst with endometrioid tumor, which is a type of malignant epithelial carcinoma (C56.1, Malignant neoplasm of right ovary). If the diagnosis is a malignant ovarian neoplasm, that changes the procedure code from 88305 to 88307 (Level V - Surgical pathology, gross and microscopic examination … Ovary with or without tube, neoplastic …) for this case.