Pathology/Lab Coding Alert

Question: The pathologist examined a bilateral oophorectomy specimen from a patient who had the procedure performed prophylactically to reduce the risk of developing ovarian cancer based on genetic mutations in the BRCA1 and BRCA2 genes. The pathology report showed no abnormality. How should we code this?

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Answer: You should code the pathology exam as 88305 (Level IV - Surgical pathology, gross and microscopic examination … Ovary with or without tube, non-neoplastic …). Although the code is singular (ovary), the pathologist received a single specimen, so you should not report two units of 88305. If the surgeon had separately identified the ovaries for individual examination and diagnosis, you would be able to report 88305 x 2.

The correct diagnosis code for the case is Z40.02 (Encounter for prophylactic removal of ovary(s)). A note following this code states, “Use additional code to identify risk factor,” so you should also report Z15.02 (Genetic susceptibility to malignant neoplasm of ovary).