L4E rule 1-3 (2014)

This article covers L4E rule 1, L4E rule 2, and L4E rule 3 for the 2014 L4E workload system. An overview of the L4E rules is found in the L4E rules of 2014.

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

Context

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

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	0.5 L4E/core (1 L3 per core)	maximum of 20 cores; should use clinicians core count (if available), if clinicians' count not available use gross count	4 breast cores = 2 L4E 12 prostate cores = 6 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.

Tutorial

The following cases can be used to work through the above rules.

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. L4E?
Answer: 6 L4E Why? Rule 2: 12 cores x 1 L3/core ~ 12 L3; 12 L3 ~ 6 L4E

11. Breast biopsy with 2 cores. L4E?
Answer: 1 L4E Why? Rule 2: 2 cores x 1 L3/core ~ 2 L3; 2 L3 ~ 1 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

See also

• L4E rules of 2014.