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Answer: The descriptor for the evaluation of a prostate biopsy is not dependent on the findings. From the information provided, you received two separate biopsy specimens for examination. According to the CPT guidelines for surgical pathology, each specimen is a separate tissue, and the accessioning, examination and reporting of each specimen is to be reported. If you have two biopsy specimens from the prostate, this should be reported as two units of 88305 (Level IV surgical pathology, gross and microscopic examination).
The diagnosis code is assigned to the highest degree of certainty at the time of coding. Because the biopsy results indicated a malignancy of the prostate, the appropriate code would be ICD9 Codes 185 (malignant neoplasm of prostate).
Answered by R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services, an independent pathology laboratory in Jonesboro, Ark.
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