Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology services (88305 x 12 units) provided 
on November 17, 2021. 
 
You asked the Plan to pay for the surgical pathology services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says there is a more appropriate 
code that should have been billed for the services rendered. 
 
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, curettings/biopsy Endometrium, curettings/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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the surgical pathology services. Our reviewer says that the 
documentation does not support the services as billed. Our reviewer found the laboratory report describes 
multiple prostate needle biopsy specimens from the same patient. In this case, per National Comprehensive 
Coding Initiative Policy Manual, Chapter 10, the services were billed incorrectly. Specifically, a more 
appropriate Healthcare Common Procedure Coding System (HCPCS) code should be reported for services 
provided. 
 
We looked at this coder's review, the file, and Medicare rules. 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 (88305 x 12 units) provided on November 17, 
2021.