Medical Coders: Focus on Fibroid Diagnosis

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

Sign up for the upcoming live audio conference, Optimize Your Fibroid Coding and Billing: The Bottom-Line Basics for the Best Reimbursement, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

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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Pennsylvania Subscriber

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

Sign up for the upcoming live audio conference, Optimize Your Fibroid Coding and Billing: The Bottom-Line Basics for the Best Reimbursement, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

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