Q: How do you code a transabdominal hysterectomy with bilateral salpingoopherectomy when the uterus has a 4-cm submucous typical leiomyoma and is submitted in one container and the bilateral fallopian tubes and ovaries are submitted in another container?
A. The correct code is one unit of 88307, Level V-surgical pathology, gross and microscopic examination; uterus, with or without tubes and ovaries, other than neoplastic/ prolapse. Because CPT specifies uterus with or without tubes and ovaries, this would be the appropriate code for this specimen. Even though the surgeon separated the specimens and they were submitted in two containers, removal of the ovaries and tubes was an integral part of the TAH-BSO procedure. Because CPT provides the specificity to code the hysterectomy, ovaries, and tubes together, it would be inappropriate to code a unit of 88305, Level IV-surgical pathology, gross and microscopic examination ovary with or without tube, non-neoplastic, in addition to the 88307 code. Repeated discussions have determined that typical leiomyomata are most appropriately coded as 88307 and not as a neoplastic lesion (88309).
Q: What code, or codes, should be used to bill for liquid-based cytology human papillomavirus testing using the Ventana technique (high-risk fluorescence in situ hybridization probe) in addition to the Pap test?
A. When pathologists perform in situ hybridization HPV testing in conjunction with a Pap test, it is appropriate to use code 88365, Tissue in situ hybridization, interpretation and report, to report this service, in addition to the primary Pap interpretation and screening codes.
Frequently asked questions about CPT are published bimonthly in “Capitol
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The codes and descriptions listed here are from Current Procedural
Terminology, 4th ed., CPT 2006. CPT 2006 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, Cap Website.