Wiki Pathology Coding Uterine Prolapse

[vkazmierczak]

I often have hysterectomy reports with a pre-op of uterine prolapse. However, findings include leiomyomas, adenomas, etc. Should I stick with the 88305 cpt coding for prolapse, or base it on the findings which could change the code to 88307 or 88309? Any advise would be appreciated. VMK

 

[preserene]

It is the surgical pathology report - and documented leomyoma or adenoma which is a neoplasm anyway. the code 88309 gives the description for neoplastic changes. I feel this more appropriate with the structural changes depicting.
In the absence of noeplasm, you can go for the changes in functional environment.

 

[whaleheadking]

Leiomyomas are not considered neoplasms for coding purposes per the December 2003 CPT Assistant, among other sources.

The code 88305 refers to a uterus removed for prolapse. Yes, the adenomas may make it neoplastic, but CPT does not distinguish between a neoplastic or non-neoplastic uterus removed for prolapse. The most accurate description is 88305. As with other specimens, the findings do not necessarily alter the specimen in this case. Other concurrent pathologies may be found on examination, but it was still removed for prolapse, and that is the condition that was being treated.

I know, life is unfair.

WK
Surgical Pathology Coding Blog.