Pathology and Laboratory Coding Case Study

Vol. 14 •Issue 16 • Page 14
Coding Corner

Pathology and Laboratory Coding Case Study


1. Left Breast

2. Right breast and right axillary nodes

3. Left tube and ovary

4. Right tube and ovary

Clinical.Information: Breast cancer, family history ovarian cancer, 1/28/99 surgery date

Gross Examination

1. This is the tissue from a modified radical mastectomy of the left breast (88307). The lobulated fatty breast tissue is 15 x 15 x 5 cm with an attached axillary portion triangular in shape measuring 8 x 5 x 1.5 cm. On the anterior surface is an ellipse of skin 7 x 2.5 cm with a central everted normal-appearing nipple. The deep surgical surface is covered in part by a white fibrous membrane with a few strands of skeletal muscle present. The breast tissue is serially sectioned and shows 90 percent lobulated homogenous fat with a few fibrous septae and a few areas of dense fibrous tissue beneath the areola. No large areas of fibrosis, cysts or tumor nodules are found. Sectioning in the area of the axillary tail fails to show any lymph nodes by gross examination.

2. The specimen is identified as right breast and right axillary nodes and consists of a 280 gram 15.5 x 14.0 x 4.0 cm right breast with a 6.5 cm axillary tail (88309). There is an overlying 10.3 x 5.2 cm tan-pink skin ellipse with a centrally placed everted nipple and areola with multinodular peripheral appearance of the areolar soft tissue. The deep surgical margin is inked. Cut section shows lobules of yellow soft adipose tissue that is transversed by thin rubbery white fibrous bands. In the mid portion of the breast tissue 1.0 cm above the deep resection margin and 1.8 cm below the skin surface is a palapable 2.5 x 2.0 x 2.0 cm mass that, on cut section, shows a finely granular tan-gray cut surface. Other indurated masses are not identified. The axillary tail is thin and enlarged lymph nodes are not readily palpated or identified. The tissue is refixed in dissect-aid to further identify lymph nodes.

3. The specimen is received in formalin, identified as left tube and ovary, and consists of a 2.8 x 0.8 cm fallopian tube stump including the fimbriated end with an adjacent 1.4 x 0.5 cm thin walled cyst (88307). There is an attached 2.8 x 2.2 x 1.3 cm ovary with an intact pale yellow capsule that, on cut section, shows corpus luteal cysts and a peripheral 0.5 cm cyst with a smooth, tan lining.

4. The specimen is received in formalin, identified as right tube and ovary, and consists of a 3.4 x 0.7 cm fallopian tube segment with a well-healed surgical stump (88307). There is a 4.0 x 2.5 x 2.4 cm ovary with a focally ruptured gray-pink capsular surface. Cut section shows a he- morrhagic corpus luteal cyst and an adjacent edematous ovarian stroma.


1. Sections of the nipple show no evidence of Paget’s disease or dermal lymphatic tumor spread. Sections of subareolar breast tissue show a benign intraductal papilloma. The breast tissue otherwise shows mild nonproliferative changes with stromal fibrosis and duct ectasia with small cyst formation. Atypical hyperplasia, in situ and invasive malignancy, are not identified.

2. Sections of the nipple show no evidence of Paget’s disease or dermal lymphatic tumor spread. Sections of mid-breast tumor show a poorly differentiated infiltrating ductal carcinoma with central area of necrosis. Tumor extends into adjacent adipose tissue and is surrounded by a moderate desmoplastic reaction. Tumor is not identified at the deep inked surgical margin. An extensive intraductal component is not identified. The tumor is composed of infiltrating trabecular cords, sheets and nests of moderately pleomorphic polygonal to oval epithelial cells, which contain a large oval to angulated nucleus with coarsely clumped nuclear chromatin, prominent and sometimes multiple nucleoli and a moderate amount of eosinophilic cytoplasm. Three to five mitotic figures are seen per high-powered field (architectural score 3, cytologic score 3, mitotic rate score 3). Sections of adjacent breast tissue show mild nonproliferative fibrocystic changes with stromal fibrosis and duct ectasia with small cyst formation. Four axillary lymph nodes show no evidence of metastatic carcinoma.

3. The fallopian tube is unremarkable. The ovary shows benign follicular and corpus luteal cysts.


1. Left breast, modified radical mastectomy (a. Benign intraductal papil-loma; b. No evidence of Paget’s disease or dermal lymphatic tumor spread; c. Mild nonproliferative fibrocystic changes, without atypia)

2. Right breast and axillary lymph nodes, modified radical mastectomy (a. Infiltrating ductal carcinoma, Elston-Bloom-Richardson grade III of III: 1. Tumor 2.5 x 2.0 x 2.0 cm in greatest dimension; 2. No evidence of tumor extension to deep surgical margin; 3. Axillary lymph nodes (four)–no evidence of metastatic carcinoma; 4. No evidence of Paget’s disease or dermal lymphatic tumor spread; 5. Pending hormone receptor and DNA analysis. b. Mild nonproliferative fibrocystic changes.

3. Left ovary and fallopian tube–benign physiological cysts, ovary. Unremarkable fallopian tube.

4. Right ovary and fallopian tube–hemorrhacic corpus luteal cyst. Unremarkable fallopian tube.

Hormone Receptor Analysis

Immunoperoxidase stains for estrogen and progesterone (88342 x 2) receptors are applied to the paraffin-embedded tissue. There are no good positive and negative internal and external controls. Tumor cells from the right breast tumor show the following staining pattern (block B5): Estrogen Receptor–negative (0% staining of tumor nuclei: H score 0); Progesterone Receptor–Negative (0% staining of tumor cells).


Hormone receptor analysis, right breast tumor: 1. Estrogen receptor–negative, and 2. Progesterone receptor–negative.

CPT Code Assignments

The following codes should be assigned for the above case study: 88307, 88309 and 88342. Be sure to note, however, the clarification below about 88342.

Assign code 88307 three times, attaching modifier 59 to two of the codes. Modifier 59 is used to indicate that this is for a distinct procedural service.

88307 Level V–Surgical pathology, gross and microscopic examination

88307-59 Level V–Surgical pathology, gross and microscopic examination

88307-59 Level V–Surgical pathology, gross and microscopic examination

Assign code 88309 once.

88309 Level VI–Surgical pathology, gross and microscopic examination

The dictation above includes the words positive/negative, which usually indicates a qualitative methodology. A number or scored type of result would indicate either a semi-quantitative or quantitative methodology. Because it appears to be a qualitative study, code 88342 would be assigned. It should be billed for each antibody, and no modifier is required because of the word “each” in the description, which indicates that the code is to be quantity billed.

88342 Immunocytochemistry (including tissue immunoperoxidase), each antibody

(For quantitative or semiquantitative immunohistochemisty, use 88361.)

The above case study was written prior to this year’s CPT code updates being re-leased, but the American Medical Association added code 88361 to the 2004 manual. It did not, however, include clear guidelines for its use. Medicare, on the other hand, has stated that it will reimburse only certain methods, and labs have been cautious about using code 88361. If the above case study was semi-quantitative or quantitative, you would assign code 88361.

88361 Morphometric analysis; tumor immunhistochemistry (e.g., Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative

HIM staff should anticipate a 2005 revision to the above CPT code for immunhistochemistry as well as the introduction of new methodology-specific CPT codes.

ICD-9-CM Code Assignments

The primary diagnosis and, therefore, the first code to be listed is the following.

174.2 Malignant neoplasm of female breast, upper-inner quadrant

There are four secondary diagnosis codes, and they should be assigned in the order listed below.

620.1 Corpus luteum cyst or hematoma

V16.3 Family history of malignant neoplasm, breast

V16.41 Family history of malignant neoplasm, ovary

V14.5 Personal history of allergy to medicinal agents, narcotic agent n

Robin Miller Zweifel is a senior health care consultant with Medical Learning Inc. (MedLearn®), St. Paul, MN, and a specialist in all areas of laboratory compliance and Medicare billing.

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