Pathology/Lab Coding Alert

Question: When our pathologist receives a uvula removed for sleep-apnea treatment, how should we code the pathology examination?


Georgia Subscriber


Answer: Because the uvula is not a listed surgical pathology specimen, your code selection is not straightforward. For examining an unlisted surgical pathology specimen, CPT instructs you to assign the code that -most closely reflects the physician work involved when compared to other specimens assigned to that code.-

Several listed CPT specimens are analogous to the uvula removed for sleep apnea because they are normal tissue removed for a therapeutic or prophylactic purpose. For example, similar listed specimens include fallopian tube or vas deferens removed for sterilization, newborn foreskin removed for circumcision, skin removed for plastic repair, or testis removed for castration. CPT lists all of these specimens under 88302 (Level II -- Surgical pathology, gross and microscopic examination). Because the work associated with a uvula removed to treat sleep apnea should be similar, you should report the service using 88302.

You would code the uvula as 88302 in other instances as well, such as when the surgeon removes the tissue incidental to a deviated septum repair. Again, 88302 lists parallel specimens such as appendix, incidental and vaginal mucosa, incidental.

Because you assign the surgical pathology level for an unlisted specimen based on the level of work relative to comparable specimens, you may be able to use a higher code for a uvula removed for cancer or other significant pathology.