Coders: Train Eyes On Fibroid Diagnosis

Figure out why you should report the pathology exam of uterus with leiomyomas as 88307

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Question: When the pathologist diagnoses uterine fibroid tumors, what ICD-9 code should we go for?

Answer: You should select the fibroid diagnosis based on the fibroids location:

Also called intracavitary fibroids, Submucous fibroids (218.0, Submucous leiomyoma of uterus) grow from the uterine wall in the direction of the uterine cavity.

Also called interstitial fibroids, Intramural fibroids (218.1, Intramural leiomyoma of uterus) grow within the uterine wall (myometrium).

Also called subperitoneal fibroids, Subserous fibroids (218.2, Subserous leiomyoma of uterus) grow outward from the uterine wall toward the abdominal cavity.

If the doctor doesnt specify the uterine fibroids location, go for 218.9 (Leiomyoma of uterus, unspecified) as the diagnosis.

CPT alert: You should report the pathology exam of uterus with leiomyomas as 88307 (Level V Surgical pathology, gross and microscopic examination, uterus, with or minus tubes and ovaries, other than neoplastic/prolapse).

Even though ICD-9 classifies leiomyoma as a benign neoplasm, a coding convention supported by the American Medical Association (AMA) and the College of American pathologists dictates that you report this condition as 88307, not 88309 (Level VI Surgical pathology, gross and microscopic examination, suterus, with or without tubes and ovaries, neoplastic).

For myomectomy specimens fibroid tumors that the surgeon removes while leaving the uterus intact you should bill the pathology exam as 88305 (Level IV Surgical pathology, gross and microscopic examination, leiomyoma[s], uterine myomectomy minus uterus).

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by: Nancy Rose

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