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Pathology/Lab Coding Alert

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Grasp Leiomyoma Exceptions

Published on Fri May 04, 2012

Question: Please help clarify how to code intramural leiomyoma findings in a uterus specimen. Does leiomyoma classify as a neoplasm?Texas SubscriberAnswer: Although leiomyoma classifies as a benign neoplasm in ICD-9 (218.1, Intramural leiomyoma of uterus for the specimen you mention), you can't claim a "neoplastic" uterus pathology exam procedure code.Exception: Even though the intramural leiomyoma is a neoplasm, you shouldn't list 88309 (Level VI -- Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, neoplastic) as the procedure code. Uterine leiomyomas represent an "unwritten" exception among listed specimens in the CPT® surgical pathology section, according to several sources, as follows:CPT®: 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 [...]
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