Reprinted from October 2003 CAP TODAY
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 bilateral fallopian tubes and ovaries in a separate
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 is code, or codes, should be used to bill for liquid-based
cytology human papillomavirus testing using the Ventana technique (high-risk
fluorescent 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
Scan.” This addition to CAP TODAY is a product of the CAP Economic
The codes and descriptions listed here are from Current Procedural Terminology,
a copyrighted publication of the American Medical Association. To purchase
CPT books, call the AMA at (800) 621-8335.