Question

question 11 (2.5 points)
a patient has a severe traumatic fracture of the humerus. during the open reduction procedure, the surgeon removes several small pieces of bone embedded in the nearby tissue. they are sent to pathology for examination without microscopic sections. the pathologist finds no evidence of disease. how should the pathologist code for his services?

88309, 88311
88304
88300
this service cannot be billed

Explanation:

Analyze the pathology service provided

The surgeon removed small pieces of bone embedded in nearby tissue during an open reduction procedure and sent them to Pathology for examination "without microscopic sections." This means only a gross (macroscopic) examination was performed.

Identify the correct CPT code for gross examination

Under CPT guidelines for Surgical Pathology, code 88300 is used for Level I - Surgical pathology, gross examination only. Codes 88302 through 88309 require both gross and microscopic examination. Since no microscopic sections were prepared or examined, the service must be coded as 88300.

Answer:

• (A) 88309, 88311
• (B) 88304
• (C) 88300 (Correct answer)
• (D) This service cannot be billed