AltheaConklin
New
Hi all,
I am looking for some authoritative guidance on the correct CPT for this specimen:
FINAL DIAGNOSIS: A RIGHT FEMORAL HEAD, TOTAL HIP ARTHROPLASTY: BONE WITH REGENERATIVE CHANGES, CONSISTENT WITH OSTEOARTHRITIS. NO MALIGNANCY IDENTIFIED.
Electronically signed by Dr. Who
Gross description: received in formalin, a right femoral head consists of 2 bone fragments measuring 4.5 x 3.0 x 1.0 cm and 5.5 x 4.5 x 3.0 cm, grossly consistent with a fragmented femoral head and neck. The articular surface is tan pink to yellow granular with extensive eburnation and osteophyte formation and attached soft tissue. Sectioning demonstrates a tan-yellow trabecular cut surface, with a 1.0 x 0.4 x 0.2cm red-pink cortical cyst. Representative sections are submitted as follows:
A1: Soft tissue
A2-A3, Bone following Decalcification
Procedure: Right Hip mako total replacement per EMR
Pre-op DX: Right Hip DJD
Per APF:
88304=femoral head without an actual break that does not include the acetabulum or femur proper resulting from hip replacement surgery. Must be head of femur bone without a significant portion of the neck although small bits of cartilage or adhered soft tissue do not affect the CPT assignment.
88305=multiple types of tissue (bone fragments, meniscus, ligament, synovium) in some combination consisting of the majority of the joint (all of the tissues are not required) submitted from a joint resection surgery and not from the repair of one of the major components of the joint. The pathologist's decision to call it a "joint resection" is binding and should be listed in the final diagnosis.
***Bone specimens often have a little soft tissue and/or cartilage attached that shouldn't be separately reported if it's apparent that it is inconsequential from a surgeon's perspective.
NOW, for the discussion at hand:
Argument for 88305: The report states "articular surface" and the final diagnosis contains "total hip arthroplasty"; the articular surface should be considered to be cartilage and the inclusion in the final diagnosis of the term "total hip arthroplasty" qualifies this as a "joint resection".
Argument for 88304: An "articular surface" is any direct surface contact (bone, cartilage) in direct surface contact with another (bone, cartilage) structure as part of a synovial joint. The "articular surface" in this report is unspecified as to the exact type of structure but also has "osteophyte formation" indicating it is bone. The soft tissue is "attached" and not part of the articular surface. The submitted specimen is listed as primarily bone and does not provide documentation of the majority of tissues that compose a joint. The submitted specimen is therefore a femoral head without a significant portion of the neck without an actual break submitted with small bits of adherent soft tissue.
I am looking for some authoritative guidance on the correct CPT for this specimen:
FINAL DIAGNOSIS: A RIGHT FEMORAL HEAD, TOTAL HIP ARTHROPLASTY: BONE WITH REGENERATIVE CHANGES, CONSISTENT WITH OSTEOARTHRITIS. NO MALIGNANCY IDENTIFIED.
Electronically signed by Dr. Who
Gross description: received in formalin, a right femoral head consists of 2 bone fragments measuring 4.5 x 3.0 x 1.0 cm and 5.5 x 4.5 x 3.0 cm, grossly consistent with a fragmented femoral head and neck. The articular surface is tan pink to yellow granular with extensive eburnation and osteophyte formation and attached soft tissue. Sectioning demonstrates a tan-yellow trabecular cut surface, with a 1.0 x 0.4 x 0.2cm red-pink cortical cyst. Representative sections are submitted as follows:
A1: Soft tissue
A2-A3, Bone following Decalcification
Procedure: Right Hip mako total replacement per EMR
Pre-op DX: Right Hip DJD
Per APF:
88304=femoral head without an actual break that does not include the acetabulum or femur proper resulting from hip replacement surgery. Must be head of femur bone without a significant portion of the neck although small bits of cartilage or adhered soft tissue do not affect the CPT assignment.
88305=multiple types of tissue (bone fragments, meniscus, ligament, synovium) in some combination consisting of the majority of the joint (all of the tissues are not required) submitted from a joint resection surgery and not from the repair of one of the major components of the joint. The pathologist's decision to call it a "joint resection" is binding and should be listed in the final diagnosis.
***Bone specimens often have a little soft tissue and/or cartilage attached that shouldn't be separately reported if it's apparent that it is inconsequential from a surgeon's perspective.
NOW, for the discussion at hand:
Argument for 88305: The report states "articular surface" and the final diagnosis contains "total hip arthroplasty"; the articular surface should be considered to be cartilage and the inclusion in the final diagnosis of the term "total hip arthroplasty" qualifies this as a "joint resection".
Argument for 88304: An "articular surface" is any direct surface contact (bone, cartilage) in direct surface contact with another (bone, cartilage) structure as part of a synovial joint. The "articular surface" in this report is unspecified as to the exact type of structure but also has "osteophyte formation" indicating it is bone. The soft tissue is "attached" and not part of the articular surface. The submitted specimen is listed as primarily bone and does not provide documentation of the majority of tissues that compose a joint. The submitted specimen is therefore a femoral head without a significant portion of the neck without an actual break submitted with small bits of adherent soft tissue.