APS performs regular audits of client report documentation, CPT®/ICD-10 code assignment and their possible relation to carrier edits. One area that APS auditors see as problematic, is proper CPT code assignment for uterus, tubes and ovaries. Following is a breakdown of this area.
88309-Uterus, with or without tubes & ovaries, neoplastic
- Excised due to suspicion of, or diagnosed, with neoplasia (malignant or benign other than leiomyoma)
- Includes both malignant and benign forms (i.e. carcinoma, carcinoma in situ, high grade dysplasia, CIN I, II, III, endometrial hyperplasia with atypia, endometrial intraepithelial neoplasia)
- Confirmed prior positive cervical biopsy
88307-Uterus, with or without tubes & ovaries, other than neoplastic/prolapse
- Removed for reason having to do with other than prolapse/neoplasia
- Cervix – squamous metaplasia (dx N87.9)
88305-Uterus, with or without tubes & ovaries, for prolapse
- Removed for prolapse when pathologist diagnoses nothing more significant (i.e. leiomyoma, endometrial hyperplasia without atypia, etc.)
88307-Ovary with or without tubes, neoplastic
- Resected due to suspicion of, or with findings of, neoplasia
- Serous cyst (dx code-N83.20) does not constitute neoplasia but serous cystadenoma (dx code-D27.9) does
88305-Ovary with or without tubes, non-neoplastic
- Resected due to medical conditions unrelated to neoplasia (i.e. follicular cyst, salpingo-oophoritis)
Fallopian tubes are always bundled with the ovaries from the same side of body and cannot be billed separately, even if submitted in separate containers, per CPT. Only if a fallopian tube biopsy is received can a separate charge be billed.
FYI - A cyst of an ovary isn’t subject to the ovary/fallopian tube or adnexa/uterus charge bundling rules. Of course, if the cyst comes to the lab as an integral feature of a resected ovary, you can’t separately bill the cyst, even if it’s separately diagnosed by the Pathologist.
Cervix is never separately chargeable when submitted with the uterus, even if separate container.
The following are scenarios when ovaries/tubes can be billed separately from the uterus when all specimens are submitted in separate containers:
- When a frozen section or intra-operative consult is performed on one or both of the separately submitted ovaries
- Clinical info (i.e., left or right adnexal mass, code appropriately per adnexal mass findings, BRCA positive = 88307) pinpoints that one or both ovaries will be separately evaluated.
- When significant pathology is found in the separately submitted ovaries (significant pathology = neoplastic, see below for examples of neoplastic vs. non-neoplastic ovaries)
If the separately submitted ovaries/tubes do not fall into one of the 3 above scenarios they are not separately billable.
The following are scenarios when ovaries/tubes can be billed separately from the uterus when submitted in samecontainer:
- When a frozen section or intra-operative consult is performed on one or both of the ovaries.
- Clinical info (i.e., left or right adnexal mass, code appropriately per adnexal mass findings, BRCA positive = 88307) pinpoints that one or both ovaries will be separately evaluated.
- When significant pathology is found in one or both of the ovaries (significant pathology = neoplastic, see below for examples of neoplasia).
- Ovaries must be separately identified in the gross description and a separate microscopic diagnosis of significant pathology is given.
If ovaries/tubes are submitted in same container and do not fall into one of the 4 above scenarios, they are not separately billable from the uterus. Use the appropriate CPT code for the uterus specimen.
Significant pathology is defined by neoplastic vs non-neoplastic as directed by ICD-10-CM. Following are examples of neoplastic vs. non-neoplastic conditions.
Examples of neoplastic ovaries:
- Carcinoma
- CIS (carcinoma in-situ)
- uncertain behavior
- serous cystadenoma
- teratoma
- dermoid cyst
- cystadenofibroma
- fibroma
Examples of non-neoplastic ovaries:
- follicular cyst
- corpus luteum cyst
- retention cyst
- serous cyst
- polycystic ovary
- endometriosis
CPT Coding Examples:
1.) Two specimens submitted
A) Uterus for fibroids
Diagnosis: Subserosal and intramural cellular leiomyoma
B) Left and Right Fallopian Tubes
Diagnosis: Fallopian Tubes with fimbriated ends with serosal vascular congestion and benign paratubal cysts
Code 88307 for Uterus other than for prolapse or neoplasia
2.) One specimen submitted
A) Uterus, Hysterectomy
Cervix: No significant pathologic abnormality
Endometrium: Cystic atrophy with hemorrhage
Myometrium: Leiomyoma
Ovary, left: Serous cystadenofibroma
Ovary, right: follicular cyst
Fallopian Tubes: No significant pathologic abnormality
Code 88307x2 for Uterus other than for prolapse or neoplasia and for neoplastic left Ovary
As one can see, it’s irrelevant if the uterus, tubes and ovaries are submitted in the same or different containers.
CPT copyright 2018 American Medical Association. All rights reserved.
Resources: AMA 2018 CPT, AAPC 2018 ICD-10, 2018 Pathology Service Coding Handbook, & College of American Pathologists.
