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Ask a Rev Cycle Expert: Pathology Specimen for Bilateral Tonsils?


What is the guidance for charging pathology for a single specimen container with bilateral (2) tonsils?


A specimen is defined as tissue or tissues that is (are) submitted for individual and separate attention, requiring individual examination and pathologic diagnosis. If the tonsils have a type of marker, such as a suture to distinguish between left and right, and labeled as needing separate pathological evaluation, then two units of service may be reported. If the tonsils are sent as a single specimen, then only one unit of service is reported.

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