Medical Coding

Category - Laboratory and Pathology

The surgical pathologist obtained three skin tags samples from in the patient’s right axilla, as well as four samples of breast tissue from the surgical session. The surgical procedure was a radical bilateral mastectomy, including excision of regional lymph nodes and surrounding tissue. How should the surgical pathologist code for this service?
  1. 88304 (X7)
  2. 88304 (X3), 88307 (X4)
  3. 88305 (X3), 88307 (X4)
  4. 88304 (X3), 88309 (X4)
Explanation
Answer: D - The surgical pathologist should code for this service using codes 88304 with 3 units, to indicate the sampling of three separate skin tags. Code 88309 with 4 units should be used to indicate the four separate samples of breast tissue. Level VI codes (88309) are more appropriate than Level V codes (88307) because the procedure was a mastectomy with removal of regional lymph nodes. If the procedure had been a partial or simple mastectomy, then code 88307 (Level V) would have been the correct surgical pathology code.
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