Through routine CPT® Coding Audits conducted by APS’ certified coding team, intestinal specimen have been identified as a reoccurring area of error amongst our clients. The following information is intended to help guide appropriate CPT code selection. Small intestine and colon 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, Including Polyp Removal
An intestinal biopsy is a small piece of tissue submitted for examination. A biopsy CPT is 88305, regardless of the final diagnosis. Biopsy specimens are typically less than 3-4 centimeters in size.
Removal of an intestinal polyp is coded as 88305, without preference to diagnosis.
Resections
Intestinal resection specimens, partial or total, are identified by the size of the specimen and documented verbiage and are CPT coded based on the outcome. 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.
• A neoplastic resection specimen is appropriately billed with 88309, regardless of partial or total removal. A resection for suspicion of neoplasia/tumor is billed as 88309 even if no neoplasia is found.
• If the specimen is non-neoplastic, and neoplasia is not suspected, resection specimens are billed with 88307.
Special Case: Total Colectomy
A case identified and documented as a total colectomy is always billed as 88309. The presence or absence of neoplasia in a total colectomy specimen does not alter the CPT charge.
Billing for Secondary Specimens
• Appendix: When removed attached to a cecum specimen, appendix is not charged unless it is identified by the surgeon for diagnostic attention or it carries significant pathology upon review. Appendix is only charged when it is of diagnostic interest.
o CPT 88302 if incidentally removed with the resection of another organ (ie. Colon other than cecum, small intestine)
o CPT 88304 if anything other than incidental
• Omentum: Keywords “biopsy” or “resection” will support the correct CPT charge in addition to size of the specimen.
o Biopsy of omentum is 88305, regardless of diagnosis. Incidental pieces of omentum attached to an intestinal resection are not separately charged.
o Resection of omentum (typically larger than 10 cm with attention directed to the specimen) is either 88307 (no neoplasia suspected or found) OR 88309 (neoplasia suspected or found)
• Lymph Nodes: Regional (paracolic) are bundled with a resection, but remote can be billed separately (i.e. pelvic or retroperitoneal). Sentinel lymph nodes are always separately charged provided they are individually identified and diagnosed.
The appropriate charge(s) should be determined case-by-case and should consider the specimen size, diagnosis, and clinical history. Keywords are essential to support proper charge capture and avoid audit requests.
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