Q. How do you code a computed tomography-guided needle biopsy of an abdominal mass that is diagnosed as adenocarcinoma?
A. The unit of service for the surgical pathology codes (CPT codes 88300–88309) is the specimen. Most specimens are defined in the surgical pathology section of CPT. Any unlisted specimen, such as abdominal mass, should be assigned to the code that most closely reflects the physician work involved.
Q. We perform approximately 6,000 Pap smears per year using the SurePath liquid-based methodology. Because we have only one cytotechnologist, one of the medical technologists who is also board-certified in cytopathology performs the quality control evaluations. We have not been charging for her evaluation of these quality control Pap smears. Can our group charge for the pathologist’s evaluation of the quality control Pap smears that our cytotechnologist has screened?
A. Pap test quality control can be performed by laboratorians other than the pathologist. Therefore it is not billable.
Q. Should a core biopsy of an upper thigh mass, with a final diagnosis of sarcoma, not otherwise specified, be reported using CPT code 88305, Level IV—surgical pathology, gross and microscopic examination, or 88307, Level V—surgical pathology, gross and microscopic examination?
A. A soft tissue mass, other than lipoma, subjected to biopsy or simple excision should be reported using CPT code 88307, Level V—surgical pathology, gross and microscopic examination
“Your CPT Questions” is a product of the CAP Economic Affairs Committee. The codes and descriptions listed here are from Current Procedural Terminology, 4th ed., CPT 2008. CPT 2008 is copyrighted by the American Medical Association. To purchase CPT books, call the AMA at 800-621-8335. For more information about CPT coding, visit the CPT Coding Resource Center on the CAP Web site