Her quote I have already given in" "LEVEL VI code 88309 includes examination of neoplastic tissue or very involved specimen". - in the previous sentences. I said based on the cpt guide lines at the start of the subsection and the text books classification of labelling I gave the inference as, 'NO CANCER NEOPLASTIC SPECIMEN IS LABELED OR LISTED INTO ANY LEVEL LESSER THAN LEVEL VI"..(you can see the list from level 1 to Level 6-just as to infer) I have read her text book well and it is very very fantastic and reliable one and I dont find any deviation from the cpt manual and the pracitices we are based on. medical analysis and critical thinking and evaluation also all the more important in coding,while assigning the code.
By the way she is one of the best authority and her text book is one of the best for Coding. Any Coder would know her by her name and profound breathtaking work and efforts in coding profession. Please do not jump into judgement like that.
My point is : for this case of discussion, 1) it was not just a kidney biopsy sample for you to assume it 'Kidney biopsy' and search for it as such in the list and find it in 88507 and just code it . It was a mass of resection tissue that was sent. Clinical relevance, the gross examination and the microscopic examination report all adds up. Any school child if you give a list and a name of the sample, to search for within that list, she or he will do it in a minute!!
For us there are certain guidelines to follow too.
If you do not find the name of the specimen(of the thousands various body tissues) in the list of 6 levels where do you place them? The list can not contain all of them.You can take, in many places, examples only and there comes our clinical/medical knowledge, critical thinking and analysis value.
Why go that far, it is not a kidney "biopsy" tissue and the reason why the surgeon took a mass of kidney tissue-from a vital organ, and sent for Sur Path examination ( Gross and Mic ), it self, will suggest that there is a great possibility of malignancy and all the more THE PATHOLOGY REPORT OF 'CARSINOMA' itself SUFFICE THE SURGICAL PATHOLOGY CLASSIFICATION LEVEL DETERMINING, BY THE COMPLEXITY OF THE PATH EXAMINATION, THE CODE BE ASSIGNED AS 88309
Thank you. I don't change my assessment until some authority from AAPC level reason out that I am wrong.