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?

Question

Quizplus · Accepted Answer

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.

The Surgical Pathologist Obtained Three Skin Tags Samples from in the Patient's