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Your CPT Questions

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Q: If an axillary tail containing eight lymph nodes is submitted as one dissection and each of the eight lymph nodes is stained with cytokeratin, how should the immunohistochemical stain be reported?

A: Code 88342, Immunohistochemistry (including tissue immunoperoxidase), each antibody, is reported once for each antibody applied to a single specimen. When multiple sections prepared from a specimen are stained with one antibody, report only one unit of 88342. Since only one antibody marker was used for the axillary tail specimen, bill one unit of 88342. If a specimen is stained with multiple different antibody markers, report 88342 once for each antibody used. If a specimen is stained with an antibody cocktail, report each antibody separately only if each one can be differentiated microscopically.

Q: We received the left and right lobes of a large nodular goiterous thyroid in separate containers solely because the surgeon divided it for ease of resection. Since CPT lists the thyroid as "total/lobe," should we bill one or two units of 88307?

A: The most correct code is likely one unit of 88307, Level V-surgical pathology, gross and microscopic examination; thyroid, total/lobe. Even though the surgeon submitted the specimens in two containers, they compose a total thyroidectomy. If the thyroid is too large to fit into one container or is split for surgical convenience, report it as one unit of 88307. An additional unit of 88307 is justified if the surgical intent is to investigate each lobe separately.

Frequently asked questions about CPT are published bimonthly in "Capitol Scan." This section of CAP TODAY is a product of the CAP Economic Affairs Committee. The codes and descriptions listed here are from Current Procedural Terminology, 4th ed., CPT 2003. CPT 2003 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.

-Carl Graziano