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Coding of specimens submitted in same container

Pam Posted Fri 27th of June, 2014 16:16:12 PM

If the surgeon submits a “hernia sac and cord lipoma” in the same specimen container, but the pathologist can differentiate and provide a diagnosis for both specimensbetween the hernia sac and cord lipoma, can we charge for both specimens?

SuperCoder Answered Mon 30th of June, 2014 10:40:32 AM

Thank you for your question.

There are two things to consider with this question. The first is the procedure. Pathology codes for specimens are based on the type of procedure performed. If the specimen is a typical specimen for that procedure, then they would not be billable as separate specimens. The second thing to consider is that if the specimens can be separately identifiable and can be diagnosed as separate specimens, billing separate can be considered as long as the documentation from the surgeon and pathologist can support separately identifiable specimens, regardless if they came in one container.

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