Pathology/Lab Coding Alert

Question: The pathologist evaluates a left-salpingo-oophorectomy specimen that the surgeon submits for a “enlarged ovarian mass.” The pathology report identifies endometrial tissue implanted in the ovary and indicates evidence of hematoma containing old blood. The pathologist also notes that the fallopian tube is unremarkable. The final diagnosis is endometrial cyst. What are the correct procedure and diagnosis codes for this case?  

Florida Subscriber

Answer: The correct procedure code is 88305 (Level IV - Surgical pathology, gross and microscopic examination … ovary with or without tube, non-neoplastic …) because the pathologist diagnoses a non-cancerous endometrial ovarian cyst.

If the pathologist had diagnosed cancer, you would instead report 88307 (Level V - Surgical pathology, gross and microscopic examination … ovary with or without tube, neoplastic …).

Caution: Even though the pathology report includes a diagnosis statement for the fallopian tube, and CPT^® provides a code for fallopian tube (88305, ... fallopian tube, biopsy…), you should not separately code the tube exam. The 88305 ovary code states, “with or without tube,” so you should not unbundle the fallopian tube as a separate specimen.

Assign diagnosis code N80.1 (Endometriosis of ovary) for the case. Don’t confuse this type of endometrial cyst with an ovarian endometrioid tumor, which is a type of malignant epithelial carcinoma. If this left-salpingo-oophorectomy specimen had been an endometriod tumor, you would code the diagnosis as (C56.2 Malignant neoplasm of left ovary).