Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on
February 25, 2021.
You asked the Plan to pay for the surgical pathology services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately
payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 88305 is Level IV - Surgical pathology, gross and
microscopic examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis
Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical
margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy
Duodenum, biopsy Endocervix, curetting/biopsy Endometrium, curetting/biopsy Esophagus, biopsy Extremity,
amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, fracture
Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection Kidney,
biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy - without uterus Lip, biopsy/wedge resection
Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy
Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or
without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary
tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp, cervical/endometrial Polyp,
colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus,
paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other
than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than
tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy
Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse
Vagina, biopsy Vulva/labia, biopsy.
We find that CPT code 88305 is not supported in the medical record. Specifically, the documentation shows
that billed place of service for this service was, place of service 81 (Independent Laboratory). If a diagnostic
test which has a separate technical component (TC) and professional component (PC) is provided under
arrangement to a hospital, the physician who reads the test can bill and be paid for the professional component.
Both the technical and professional components of the test are also subject to the physician self-referral
prohibition. The appropriate place of service code for the interpretation (or PC) is the setting where the
beneficiary received the TC service. This means that this service was billed with an incorrect place of service.
Based on this information, we decided that Medicare rules for coverage of the surgical pathology services have
not been met. Therefore, we decided that the Plan does not have to pay for the surgical pathology services
coded 88305 provided on February 25, 2021