Gastric specimen billing is determined by several factors. Pathologists should be prepared to carefully document the clinical history, specimen type, gross description and final diagnosis.
Biopsies
A stomach biopsy is a small piece of gastric tissue submitted for examination. A biopsy CPT® is 88305, regardless of the final diagnosis. Multiple biopsies can be submitted on a report as long as their location is separately identified (antrum, body of stomach, etc.). Biopsy specimens are typically less than 3-4 centimeters in size. Removal of a gastric polyp is also coded as 88305.
Resections
Stomach resection specimens, partial or total, are identified by the size of the specimen and are CPT coded based on the outcome. A neoplastic resection specimen is appropriately billed with 88309, regardless of partial or total removal. If the specimen is non-neoplastic, the charge would be 88307. Specimens in this category are larger than a biopsy. The charge is supported by other documented work (number of blocks/slides) and the keyword resection should be included in the specimen description for proper identification.
Special Cases: Bariatric Specimens
Gastric bypass cases are billed following the above guidelines. Some bariatric specimens are small and would be appropriately coded as 88305. In the case of resections, whether subtotal or total, CPT 88307 is appropriate unless there is neoplasia identified in the specimen after removal. For gastric bypass specimens there are two major considerations:
1. How large is the specimen?
2. Is neoplasia present or suspected per clinical history?
The appropriate charge should be determined case-by-case by the pathologist and should consider the specimen size, number of blocks/slides and any other factors influencing the work to evaluate the specimen. Keywords are essential to verify proper charge capture: biopsy or simple excision would support 88305, while resection would support 88307. Per the AMA, code 88307 is properly applied for a resection specimen when surgery is performed due to concern for a condition other than tumor, and tumor is not identified during the microscopic examination.
The appropriate CPT code for gastric specimens is determined by clinical history, size, final diagnosis, and keyword descriptors. Precise documentation of these elements will support the CPT charges applied to the case.
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