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Question: A patient had a cesarean section (C-section) and had bilateral tubal ligation during the procedure. Pathology documentation shows separate specimens for the left and right fallopian tubes along with the placenta. I am billing for the professional side and the charges drop into my queue from facility side. I am being told to bill 88304 for fallopian tubes that are sent exclusively related to sterilization and nothing is found. Am I correct that these should be 88302?

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Answer: The CPT^庐 guidelines accompanying the Surgical Pathology codes state that 鈥渓evels 88302 through 88309 are specifically defined by the assigned specimens.鈥� Your question states the specimens your pathologist obtained are the patient鈥檚 fallopian tubes and placenta; as the patient had undergone a C-section, that would indicate the placenta was taken during the third trimester.

In this situation, 88304 (Level III - Surgical pathology, gross and microscopic examination 鈥�) would not be appropriate, as neither of those specimens are mentioned in that code. Instead, you would use both 88302 (Level II - Surgical pathology, gross and microscopic examination 鈥� Fallopian tube, sterilization 鈥�) and 88307 (Level V - Surgical pathology, gross and microscopic examination 鈥� Placenta, third trimester 鈥�), as these codes specifically name the specimens your pathologist examined.

Remember: You would use 88302 on the fallopian tube pathology providing the 鈥渆xamination is performed on a specimen to confirm identification and the absence of disease,鈥� per CPT^庐 guidelines. A fallopian tube biopsy would bump the surgical pathology level up to 88305 (Level IV - Surgical pathology, gross and microscopic examination 鈥� Fallopian tube, biopsy 鈥�) for that specimen.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC