Specimen Bundling - Colon Resection

Case Scenario: A pathologist receives a cecum with attached appendix and gallbladder from a partial colon resection. The tissues are submitted in one container.

Q: What specimen(s) may be coded separately in this situation?

A: In most circumstances, a cecum with the attached appendix is bundled into the colon resection service because the appendix is an integral part of the resection specimen that is not diagnostically significant. The appropriate code for the colon segment/appendix is based on whether the resection is for a tumor or some other reason. The two codes applicable are:

· CPT^® 88307- segmental resection, other than for tumor

· CPT^® 88309 – segmental resection for tumor.

If the surgeon specifically identifies the appendix for separate examination such as by suturing, inking and/or specifically requests appendix exam on the order form, the pathologist may separately report the appendix, provided a separate documented diagnosis for the appendix is in the final report. In addition, if the pathologist identifies and reports a significant, distinct pathologic finding for the appendix apart from the colon diagnosis - even if the surgeon did not separately identify the appendix - the pathologist also may separately code for the appendix. The appropriate code selection would be either:

· CPT^® 88302 – appendix, incidental

· CPT^® 88304 – appendix, other than incidental

The gallbladder is not a common, attached tissue that is part of a colon resection. Therefore, the pathologist should separately code for that service, provided the final report indicates a separate diagnosis for the gallbladder. The appropriate code is CPT^® 88304 – gallbladder.

Rick Oliver, CHCO, CPC, MT(ASCP)

Director of Compliance - Pathology

McKesson Revenue Management Solutions

CPT is a registered trademark of the American Medical Association. All rights reserved.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Coding Q & As are the interpretation or explanation of McKesson (RMS) and not necessarily the AMA’s and not necessarily the position an agency checking the accuracy of coding would adopt. This publication is not intended to constitute legal, accounting, financial, investment or other professional advice. Any coding or business decisions should be made in consultation with your legal, professional and/or accounting advisors.