Find out why you should code the pathology exam of uterus with leiomyomas as 88307.
Question: When our pathologist diagnoses uterine fibroid tumors, what ICD-9 code should we use?
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Answer: You should choose the diagnosis based on the fibroid’s location:
- Submucous fibroids (218.0, Submucous leiomyoma of uterus) grow from the uterine wall toward the uterine cavity. They are also called intracavitary fibroids.
- Intramural fibroids (218.1, Intramural leiomyoma of uterus) grow within the uterine wall (myometrium). They are also called interstitial fibroids.
- Subserous fibroids (218.2, Subserous leiomyoma of uterus) grow outward from the uterine wall toward the abdominal cavity. They are also called subperitoneal fibroids.
- If the physician does not specify the uterine fibroid’s location, assign 218.9 (Leiomyoma of uterus, unspecified) as the diagnosis.
CPT alert: You should code the pathology exam of uterus with leiomyomas as 88307 (Level V — Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, other than neoplastic/prolapse).
Although ICD9 classifies leiomyoma as a benign neoplasm, a coding convention supported by the American Medical Association and the College of American Pathologists dictates that you code this condition as 88307, not 88309 (Level VI — Surgical pathology, gross and microscopic examination, uterus, with or without tubes and ovaries, neoplastic).
For myomectomy specimens — fibroid tumors that the surgeon removes while leaving the uterus intact — bill the pathology exam as 88305 (Level IV — Surgical pathology, gross and microscopic examination, leiomyoma[s], uterine myomectomy — without uterus).
@ Pathology/Lab Coding Alert. Editor: Ellen Garver, CPC
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