Q. Our pathologists reviewed a colon biopsy submitted from a diagnostic colonoscopy. The patient was having rectal bleeding with left lower quadrant pain. The final diagnosis was “no abnormal findings.” How do we ICD-9 code this case?
A. As the specimen was found to be “normal,” the appropriate ICD-9 code to report would be the physician’s ordering diagnosis, report 569.3 (bleeding; rectal) with 7890.4 (LLQ; pain). If the pathology report had indicated a specific finding, that would have been the code to report. For example, if the finding was inflammation, the ICD-9 code to report would be 558.9 (inflammation; colon) instead of the ordering diagnosis.
Q. We received a breast specimen submitted to us on July 15 for exam and a final diagnosis of adenocarcinoma was given. Now on September 10 an order is received asking that KRAS mutational analysis be performed. We pulled the slides from storage and chose the appropriate block containing the tumor cells and sent it on. Is there a code to report this service?
A. The code to report is CPT 88363 (Examination and selection of retrieved archival tissue(s) for molecular analysis.) The date to report would be September 10 as this is the date the specimen was retrieved from the archives.
Salt Lake City, UT