Pathology/Lab Coding Alert

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.   Question: How should I code the evaluation of sinus contents along with a portion of the nasal septum (cartilage and bone)?

North Carolina Subscriber
  Answer: The specimen you describe is common when a surgical procedure is performed for chronic sinusitis (e.g., 473.0). Assuming that the septum and nasal contents are not separately identifiable, as is often the case with this type of specimen, the proper code is CPT 88304 (Level III Surgical pathology, gross and microscopic examination, polyps, inflammatory nasal/sinusoidal). A decalcification procedure is often also required for a specimen like this, and should be reported with +88311 (Decalcification procedure [list separately in addition to code for surgical pathology examination]).

It is not appropriate to report this specimen with 88305 (Level IV Surgical pathology, gross and microscopic examination, nasal mucosa, biopsy) because the description does not indicate that the specimen is submitted for evaluation for neoplasm. Any specimen that is essentially a debridement of the nasal cavity (nasal turbinates, sinus polyps, etc.) is reported with 88304. If the left and right nasal contents are separately identified and submitted for individual evaluation and diagnosis, two units of 88304 may be reported. However, the description you gave does not warrant separate reporting of the left and right sinus contents.