Christine Posted Wed 01st of November, 2017 14:43:09 PM
Should this be coded as 88302 for identification only and 88304 for hypertrophy?
SuperCoder Answered Thu 02nd of November, 2017 03:14:51 AM
It is an oversimplification to say that you should only and always report 88302 when the pathologist identifies tissue and confirms absence of disease. Although CPT states, 88302 is used when gross and microscopic examination is performed on a specimen to confirm identification and absence of disease.
Since uvula is an unlisted specimen, it should be assigned a code based on the level of work involved to evaluate the specimen (hypertrophied in your case), this would be 88304.
Codes 88302-88309 represent ascending levels of pathologist work for the gross and microscopic exam of tissue specimens. Each code includes a number of listed specimens, and one should report that code when the pathologist examines a listed specimen.