Uterus, Fibroids and Prolapse

You receive a uterus submitted for prolapse for gross and micro examination, leiomyomas are found. How do you code this?  A uterus is submitted for menorrhagia.  No significant pathology is found.  What CPT code do you assign?  Have you ever had these types of case scenarios and were unsure of the correct code to assign? There are many guidelines to follow for hysterectomy cases and, per CPT, there are three choices of codes for uterus with and without ovaries and tubes, in addition to CPT codes for ovaries with and without tubes and fallopian tube plus a specific CPT code for leiomyoma(s), uterine myomectomy-without uterus.  The three codes for uterus with or without tubes and ovaries and their descriptions are:

⇒ 88305 - Uterus; with or without tubes and ovaries, for prolapse

⇒ 88307 - Uterus; with or without tubes and ovaries, other than neoplastic/prolapse

⇒ 88309 - Uterus; with or without tubes and ovaries, neoplastic

Report 88305 for a uterus submitted with clinical history of prolapse and no significant pathology is noted.  But, if significant pathology is diagnosed such as endometriosis, leiomyoma, CIN III, you would report one of the other two code choices, either 88307 or 88309.  You would bill for the work on the findings, not the clinical information. 

Please note leiomyoma is a type of neoplasm, but per CAP, AMA and CMS “leiomyomas do not require the same degree of evaluation as other uterine neoplasms.” So, when a leiomyoma is the principle diagnosis for a hysterectomy specimen it is properly reported with code 88307.

There may be a case when a patient may only have the leiomyoma(s) removed (myomectomy) leaving the uterus.  Per CPT, report 88305 for uterine fibroids for each separately identified leiomyoma specimen.  If a myomectomy is done followed by a hysterectomy, two separate specimens are submitted and in this instance you can report 88305 for the leiomyoma and 88307 for non-neoplastic uterus. 

Besides leiomyomas, code 88307 is reported for all other non-neoplastic conditions such as endometriosis, adenomyosis or for clinical signs and/or symptoms such as menorrhagia, abnormal bleeding, etc.  Code 88309 is reported for all neoplastic conditions and would include if the patient had clinical information of a prior biopsy with carcinoma in situ.