Pathology/Lab Coding Alert

Question: When our pathologist is called into surgery for immediate diagnosis of a breast needle-core biopsy and examines a touch prep slide rather than frozen sections, how should we report the service? Can we code separately for the opinion in surgery, the touch prep and the final diagnosis of the needle core specimen?


Michigan Subscriber


Answer: For going to surgery and providing an opinion on the needle-core biopsy, you should charge for a pathology intraoperative consultation. Because the pathologist did not perform frozen section evaluation, you should report the consultation as 88329 (Pathology consultation during surgery).

The proper code for touch prep is CPT 88161 (Cytopathology, smears, any other source; preparation, screening and interpretation). You can report the touch prep in addition to the intraoperative consult (88329) because the pathologist did not also perform frozen section evaluation. If the pathologist examines frozen sections (88331, Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen) and touch prep slides, you cannot separately report the touch prep because a National Correct Coding Initiative edit bundles 88161 with 88331 for the same specimen.

You should report the pathologist's exam of the breast needle-core biopsy specimen using the appropriate surgical pathology code, which is 88305 (Level IV - Surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins). A needle-core biopsy does not usually involve margin evaluation, whether the lesion is benign or malignant, because the surgeon has not excised the entire lesion.

Because NCCI edits also bundle 88161 with 88305, you would have to append modifier 59 (Distinct procedural service) to 88161 to indicate that the touch prep was part of the separate intraoperative consultation (88329) and not part of the surgical pathology specimen exam (88305).