Pathology/Lab Coding Alert

You'll need to know more than just specific code definitions if you want to get your referred-material pathology consultation coding right. Let us show you the broader documentation requirements to make sure you get paid -- every time.

Recognize the options: When an outside institution sends previously diagnosed cytology or histology slides and/or tissue with a request for your pathologist's review, you can bill a consult code for your pathologist's diagnosis and report using one of the three following codes:

• 88321 -- Consultation and report on referred slides prepared elsewhere

• 88323 -- Consultation and report on referred material requiring preparation of slides

• 88325 -- Consultation, comprehensive, with review of records and specimens, with report on referred material.

All consultations require the 3 R's -- request (from an independent physician), render (medical opinion), and report (findings).

To bill a pathology consult, you must have a consult request from an outside physician or institution on file, and the consulting pathologist must issue a formal medical report, according to Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., publisher of the Pathology Service Coding Handbook, in The Villages, Fla.

Exception: If a physician on your hospital staff requests a pathology consult to confirm prior pathologicdiagnosis for a transfer patient from another care center, you can still bill these codes.

Codes 88321-88325 report ascending levels of consultation complexity. Choosing the correct code is as easy as 1-2-3:

1. Use 88321 when the pathologist reviews only previously prepared slides.

2. Report 88323 when your lab must prepare slides from referred tissue before the pathologist examines the slides. Read "3 Tips Solve Outside Consult Puzzle" on page 100 to learn the ins and outs of using this code with routine stains, such as hematoxylin and eosin (H&E), and special stains.

3. Reserve 88325 for when the pathologist reviews the full patient history, such as surgical notes and oncology reports, along with the tissues and slides.