Pathology/Lab Coding Alert

Clinical laboratory test results often are returned as a computer-generated report or, under some circumstances, with a pathologists interpretation of those results. If more than a routine report or interpretation is called for, the pathologist may be able to capture the service as a clinical pathology consultation. If the three Rs and the four standards are met, it is a consultation.

Criteria for Clinical Pathology Consultation Codes

According to Laurie Castillo, MA, CPC, president of American Academy of Professional Coders Northern Virginia Chapter and owner of Physician Coding & Compliance Consulting in Manassas, Va., there are two codes for clinical-pathology consultations. One is for a limited service, 80500 (clinical pathology consultation;limited, without review of patients history and medical records), and one is for a more extensive service, 80502 (comprehensive, for a complex diagnostic problem, with review of patients history and medical records). These are professional-service-only codes, meaning that there is no technical component involved.

These codes are for a very specific consultation service relating to communication with an attending physician about results of clinical laboratory tests, Castillo says. As with other CPT consultation codes, certain criteria must be met and documented in the medical record for the service to be considered a consultation.

The three-R test always helps to identify a consultation:

a request (for a consultation);
a review (of an abnormal test result); and
a report (written).

These four standards offer further clarification:

1. A patients attending physician, from the same or another institution, must request the consultation. Another physician ordering the test does not constitute a request for consultation. A standing order cannot substitute for an individual physician request for Medicare patients.

2. A consultation must relate to an abnormal test result, based on the condition of the patient. In other words, the test result must be outside of the clinically significant expected range.

3. A clinical pathology consultation requires the exercise of medical judgment by the consulting pathologist. This pathologists opinion should be applicable to the attending physicians management of the patient.

4. A consultation must result in a written report that is included in the patients medical record.

Meeting the three Rs and four standards would qualify the service as a clinical-pathology consultation. According to the April 1997 issue of CPT Assistant, codes 80500-80502 should not be reported if the clinical pathologist has already performed a consultation and reported on referred material or slides (88321-88325). Finally, Castillo points out that if the pathologists consultation involves examination and evaluation of the patient, codes 99241-99275 (evaluation and management consultations) should be used.

Medicare Rules

The Health Care Financing Administration (HCFA) provides direction for these codes in the Medicare Carriers Manual section 15020. The following example is furnished there [...]