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88309 Hysterectomy

Gladys Posted Thu 18th of February, 2016 09:59:55 AM

My manager and I disagree on whether a hysterectomy should be an 88307 vs an 88309:

Patient has pelvic pain and menorrhagia.

A hysterectomy is performed. Pathology reveals mild dysplasia/CIN I and HPV

My manager says it should be coded as an 88307 unless it is Carcinoma in situ or carcinoma/cancerous, CIN III/cancer.

My reasoning is this: the fact that mild dysplasia is CIN I. This is a cervical intraepithelial neoplasia. The term neoplasia refers to a mass that has developed due to abnormal cell or tissue growth. Neoplasia refers to various types of growths including non-cancerous or benign tumors, precancerous growths, carcinoma in situ and malignant or cancerous tumors. The CPT book states Uterus/hysterectomy specimens for neoplasm is an 88309. It does not say malignant neoplasm. Therefore I have been wanting to do 88309 for these.

What is your opinion on this matter?


SuperCoder Answered Fri 19th of February, 2016 02:34:39 AM

Appropriate code for this scenario would be 88307.
Dysplasia is the medical term for abnormal cells on the cervix caused by the HPV virus. If the abnormalities are mild and few in number, they usually go away without treatment. However, some cases of moderate dysplasia, and most cases of severe dysplasia, will not go away on their own. At this stage, the cells are considered "pre-cancer": In other words, if they are not found and treated, they could develop into cervical cancer
Mild, or "CIN 1": CIN stands for cervical intraepithelial neoplasia. If the dysplasia is "level 1," that means only about one-third of the cervical cells are abnormal. In addition, the cells don't look as clearly abnormal as in moderate or severe dysplasia. It's estimated that one out of six women will develop CIN 1, which usually goes away on its own and does not require treatment. CIN 1 also may be called LSIL (low-grade squamous intraepithelial lesion).

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