College of American Pathologists

  Your CPT Questions


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 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 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 Affairs Committee.

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.