Q: A 35-year-old BRCA1 mutation-positive patient presented for removal of her right fallopian tube and ovary. (Her left tube and ovary were removed years ago for an ectopic pregnancy.) The tube and ovary were serially sectioned, examined grossly, and embedded in paraffin. Sections from each paraffin block were examined microscopically. No cancer was found. What CPT code should we use?
A: CPT has code 88307, Level V—Surgical pathology, gross and microscopic examination, ovary with or without tube, neoplastic, for a neoplastic ovary and tube and code 88305, Level IV—Surgical pathology, gross and microscopic examination, ovary with or without tube, non-neoplastic, for a non-neoplastic ovary and tube. There is no code specifically for the gross and microscopic evaluation of tissues from patients with a genetic predisposition to neoplasms.
BRCA mutation-positive ovaries submitted for evaluation may require the pathologist to perform the work consistent with an “ovary with or without tube, neoplastic,” or code 88307. In this case, extensive sectioning was performed and the entire specimen was evaluated microscopically, so code 88307 is appropriate. If the organs were not submitted in their entirety, then it would be more appropriate to use code 88305.
Q: Should we use CPT code 88307, Level V—Surgical pathology, gross and microscopic examination, lymph nodes, regional resection, or 88305, Level IV—Surgical pathology, gross and microscopic examination, lymph node, biopsy, for a specimen labeled “left pelvic lymph node” when two separate and distinct nodes are present? In other words, how many nodes are needed to call them regional, and does it matter if the specimen is called singular or plural?
A: The pathologist should determine what level of CPT code best accommodates the work performed because pelvic lymph node samples vary and are influenced by the information provided by the submitting surgeon.
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 2007. CPT 2007 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.