Question

question 9

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?

88304
88309, 88311
88300
this service cannot be billed

Explanation:

Analyze the specimen and procedure

The specimen consists of small pieces of bone removed during an open reduction of a traumatic fracture of the humerus, which are sent to pathology for examination without microscopic sections (gross examination only).

Identify the correct CPT code

According to CPT guidelines, surgical pathology code 88300 is used for Level I - Surgical pathology, gross examination only. This code is appropriate when a specimen is submitted for gross examination only, without microscopic examination, and is not specifically listed under another level.

Evaluate the options

• 88304: Level III surgical pathology (requires microscopic examination).
• 88309, 88311: Level VI surgical pathology and decalcification (requires microscopic examination).
• 88300: Level I surgical pathology, gross examination only (matches the scenario).
• This service cannot be billed: Incorrect, as a gross-only examination is billable under 88300.

Answer:

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