Clinical History: Chronic hypertrophic tonsils; tonsillitis.
Specimen A: Specimen submitted as “Right tonsil,” and consists of pink-tan rubbery ovoid tissue measuring 2.5 x 2.0 x 1.2 cm. Cut section reveals pink-tan, homogeneous tissue. Representative section submitted in one cassette for microscopic examination labeled “A”.
Specimen B: Specimen submitted as “Left tonsil,” and consists of pink-tan rubbery ovoid tissue measuring 2.5 x 1.8 x 0.7 cm. Cut section reveals pink-tan, homogeneous tissue. Representative section submitted in one cassette for microscopic examination labeled “B”.
Specimen C: Specimen submitted as “Adenoids,” and consists of multiple fragments of glistening pink-tan tissue, which measure 1.5 x 1.1 x 0.6 cm in aggregate. Representative sections submitted in one cassette for microscopic examination labeled C”.
Specimens A and B – Right and Left Tonsils: Hyperplastic tonsils.
Specimen C – Adenoids: Hyperplastic adenoids.
Question: Is it appropriate to code three units of 88304 for this scenario?
No, only two units of 88304 (Tonsil and/or adenoids) should be assigned; one unit for the right tonsil, and one unit for the left tonsil, and the adenoids bundled with one of the tonsil specimens.
The right tonsil, left tonsil and adenoids were submitted in separate containers, which may mistakenly lead to coding each specimen individually. Separate containers are not the only factor when coding these specimens - you must first understand the role of “and” vs. “or” in the CPT code descriptor. The word “and” requires that adenoids always be bundled with the tonsil specimen(s). The word “or” allows the 88304 code to be assigned when adenoidal tissue is submitted without a tonsil specimen. Since the CPT descriptor specifies “Tonsil” singularly, this allows for individual coding when the surgeon documents separate designation of the right from left by some means such as tagging with a suture or submitting in separate containers (when the container/specimen is identified as right and left). If bilateral tonsils are submitted without designation by the surgeon, then they are considered a single specimen, coded as a single unit of 88304. Any adenoidal tissue received would bundle into that same unit.
In preparation for ICD-10 coding, the following diagnosis codes are listed for hypertrophy of tonsils and/or adenoid specimens. The chart below provides the coding differences between the ICD-9-CM and the ICD-10-CM assignment.
A single code encompasses hypertrophy of tonsils and adenoids whether you are coding with ICD-9 (474.10) or ICD-10 (J35.3), as either of these codes represent the highest level of specificity.
2012 ICD-9-CM Manual (American Medical Association)
2014 Draft ICD-10-CM Manual (Optum)
College of American Pathologists. (February 2000). Your CPT Questions
This commentary is a summary prepared by McKesson’s Business Performance Services division and highlights certain changes, not all changes, in 2014 CPT® codes relating to the specialty of pathology. This commentary does not supplant the American Medical Association’s current listing of CPT® codes, its documentation in the annual CPT Changes publications, and other related publications from American Medical Association, which are the authoritative source for information about CPT® codes. Please refer to your 2014 CPT® Code Book, annual CPT® Changes publication, HCPCS Book and Payer Bulletins for additional information, including additions, deletions, changes and interpretations that may not be reflected in this document.
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