L4E rule 1-3 (2018)

This article covers L4E rule 1, L4E rule 2, and L4E rule 3 for the 2018 L4E workload system. An overview of the L4E rules is found in the L4E rules of 2018.

Context

• This rule covers most biopsies/curettages.
• Special biopsies (e.g. medical liver, transplant biopsies) are coded differently, see L4E article.

History

• Rule 1 and Rule 3 are unchanged from Level 4 equivalent of 2014.
• Rule 2 was changed to lower the value of prostate core biopsies sets with a large number of cores; compare with L4E rule 1-3 (2014).

Details

Specimen type(s)	Weight (L4E)	Details	Examples	Rule
Complex skin biopsies and non-GI biopsies with countable fragments	1 L4E / 5 tissue fragments (frags), all fractions are rounded down	1-5 frags = 1 L4E, 6-10 frags = 2 L4E, 11-15 frags = 3 L4E, 16-20 frags = 4 L4E "complex skin" includes inflammatory skin, malignancies except BCC and SCC, atypical melanocytic lesions, adnexal tumours, lymphoid infiltrates	inflammatory skin biopsy 3 frags = 1 L4E, adnexal skin tumour 6 frags = 2 L4E	Rule 1
Simple skin (non-complex skin)	0.5 L4E/biopsy (1 L3/biopsy)	biopsies > 2 cm - use L4E rule 4; includes BCC, SCC, actinic keratosis, intradermal nevus	punch biopsy of BCC = 0.5 L4E, shave biopsy of seborrheic keratosis = 0.5 L4E	Rule 1
Medical GI biopsies	1 L3/3 tissue fragments (frags), all fractions are rounded down; 1 L3 = 0.5 L4E	1-3 frags = 0.5 L4E, 4-6 frags = 1 L4E, 7-9 frags = 1.5 L4E, 10-12 frags = 2 L4E, 13-15 frags = 2.5 L4E, 16-18 frags = 3 L4E, 19-21 frags = 3.5 L4E, 22-24 frags = 4 L4E	6 frags colorectal biopsies = 1 L4E	Rule 1
Surgical GI biopsies (neoplastic/pre-neoplastic)	1 L3/lesion (if submitted in one block) and low grade; lesion with high-grade dysplasia = 1 L4E	lesions submitted in >1 block: use L4E rule 4	2 HP polyps in one block = 1 L4E, 1 tubular adenoma negative for HG dysplasia = 0.5 L4E	Rule 1
Breast core biopsies & prostate core biopsies	1 L4E for 1st core + 0.25 L4E for each additional core + 3 L4E for synoptic (if mandated - see L4E rule 5)	should use clinicians core count (if available), if clinicians' count not available use gross count	4 breast cores = 1.75 L4E 12 prostate cores (without synoptic report) = 3.75 L4E 12 prostate cores (with synoptic report) = 6.75 L4E	Rule 2
Core biopsies (not including prostate, breast)	1 L4E / 5 cores, all fractions are rounded down	1-5 cores = 1 L4E, 6-10 cores = 2 L4E, 11-15 cores = 3 L4E, 16-20 cores = 4 L4E	3 cores of lymph node = 1 L4E, 6 cores of mediastinal mass = 2 L4E	Rule 2
Fragmented tissue/ curettage	1 L4E / 3 blocks, all fractions are rounded down	1-3 blocks = 1 L4E, 4-6 blocks = 2 L4E, 7-9 blocks = 3 L4E, 10-12 blocks = 4 L4E, 13-15 blocks = 5 L4E, 16-18 blocks = 6 L4E, 19-21 blocks = 7 L4E	endometrial biopsy in 2 blocks = 1 L4E, TURP in 7 blocks = 3 L4E, bladder biopsy in 12 blocks = 4 L4E	Rule 3

Tutorial

The following cases can be used to work through the above rules. If one clicks "Expand" on the right side one gets the answer with an explanation. It is presumed that no additional stains or levels are done.

1. Three cores of a neck lymph node. L4E?
Answer: 1 L4E Why? Rule 1: 1-5 frags ~ 1 L4E; see complex skin biopsies and non-GI biopsies with countable fragments

2. Six cores of a mediastinal mass. L4E?
Answer: 2 L4E Why? Rule 1: 6-10 frags ~ 2 L4E; see complex skin biopsies and non-GI biopsies with countable fragments

3. Two punch biopsies of BCC. L4E?
Answer: 1 L4E Why? Rule 1: each (simple skin) biopsy is 1 L3

4. Two punch biopsies (centre of lesion + edge of lesion) for an inflammatory skin lesion. L4E?
Answer: 1 L4E Why? Rule 1: complex skin biopsies for same purpose

5. Colonic tubular adenoma negative for HGD. L4E?
Answer: 0.5 L4E Why? Rule 1: 1 L3/lesion; see surgical GI biopsies (neoplastic/pre-neoplastic)

6. Colonic tubular adenoma with HGD. L4E?
Answer: 1 L4E Why? Rule 1: HGD makes it worth more; see surgical GI biopsies (neoplastic/pre-neoplastic)

7. Colonic tubular adenoma negative for HGD and hyperplastic polyp in same container. L4E?
Answer: 1 L4E Why? Rule 1: 1 L3 for TA, 1 L3 for HP - together ~ 1 L4E

8. Random colonic biopsies 15 frags. L4E?
Answer: 2.5 L4E Why? Rule 1: 15 frags x L3/3 frags ~ 5 L3, 5 L3 ~ 2.5 L4E

9. Random colonic biopsies 20 frags. L4E?
Answer: 3 L4E Why? Rule 1: 20 frags x L3/3 frags ~ 6.66 L3 -> truncated to 6 L3, 6 L3 ~ 3 L4E

10. Prostate biopsy with 12 cores without synoptic report. L4E?
Answer: 3.75 L4E Why? Rule 2: 1 L4E (first core) + 11 cores x 0.25 L4E/core ~ 3.75 L4E

11. Breast biopsy with 2 cores. L4E?
Answer: 1.25 L4E Why? Rule 2: 1 L4E + 0.25 L4E ~ 1.25 L4E

12. Endometrial biopsy in 2 blocks. L4E?
Answer: 1 L4E Why? Rule 3: 1-3 blocks ~ 1 L4E

13. Benign TURP in 4 blocks. L4E?
Answer: 2 L4E Why? Rule 3: 4-6 blocks ~ 2 L4E

14. Benign TURP in 6 blocks. L4E?
Answer: 2 L4E Why? Rule 3: 4-6 blocks ~ 2 L4E

15. Endometrial biopsy in 5 blocks. L4E?
Answer: 2 L4E Why? Rule 3: 4-6 blocks ~ 2 L4E

16. Benign TURP in 8 blocks. L4E?
Answer: 3 L4E Why? Rule 3: 7-9 blocks ~ 3 L4E

Quiz

You can test your knowledge in the L4E rules 1-3 quiz.

See also

• L4E rules of 2018.
• L4E rule 1-3 (2014).