Pathology/Lab Coding Alert

Answer: The correct coding for pathology examination of a skin tumor with evaluation of margins using two frozen sections is as you indicated: 88305 (level IV surgical pathology, gross and microscopic examination, skin, other than cyst/tag/debride-ment/plastic repair) 88331 (pathology consultation during surgery; first tissue block, with frozen section[s], single specimen) and CPT 88332 (pathology consultation during surgery; each additional tissue block with frozen section[s]). Note that if there had been a third block, you should report an additional unit of 88332.

The wording for the frozen sections was changed in CPT 2001 to clarify the use of these codes. The words first tissue block were added to code 88331 to clarify that the first tissue block for frozen sections from a single specimen is reported with this code. Any subsequent blocks from the same specimen are reported as 88332, each. If the margins show tumor involvement and the surgeon subsequently takes additional tissue and requests frozen sections, it represents a separate specimen and should be reported just like the first specimen. Report the pathology examination of the specimen as 88305, the first frozen section as 88331, and each additional frozen section (if any) as 88332.

Answered by R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services, an independent pathology laboratory in Jonesboro, Ark.