Pathology/Lab Coding Alert

Here’s how to get time on your side.

In 2021, the Centers for Medicare & Medicaid Services (CMS) released the 2022 Medicare Physician Fee Schedule, which included College of American Pathology- (CAP-) developed pathology consultation codes. The AMA worked closely with CAP to develop these codes to improve physician service reporting and billing.

Because these codes are relatively new, there’s still some confusion about how to use them, especially as you can use time or medical decision making (MDM) to determine the correct level of services to bill. Here’s what you need to know to apply these physician service codes correctly.

Understand the Changes in Consultation Reporting

In 2022, the AMA deleted the following CPT^® codes:

• 80500 (Clinical pathology consultation; limited, without review of patient’s history and medical records)
• 80502 (… comprehensive, for a complex diagnostic problem, with review of patient’s history and medical records)

In their place, CPT^® introduced the following to describe physician pathology clinical consultation services:

• 80503 (Pathology clinical consultation; for a clinical problem, with limited review of patient’s history and medical records and straightforward medical decision making. When using time for code selection, 5-20 minutes of total time is spent on the date of the consultation)
• 80504 (… for a moderately complex clinical problem, with review of patient’s history and medical records and moderate level of medical decision making. When using time for code selection, 21-40 minutes of total time is spent on the date of the consultation)
• 80505 (… for a highly complex clinical problem, with comprehensive review of patient’s history and medical records and high level of medical decision making. When using time for code selection, 41-60 minutes of total time is spent on the date of the consultation)
• +80506 (… prolonged service, each additional 30 minutes (List separately in addition to code for primary procedure))

The purpose of the new codes is to clearly delineate the details, time, and intensity of pathology clinical consultations in more detail. The new codes allow more transparency into the level of work the pathologist performed, contributing to more accurate reimbursement for services rendered. The codes also allow the option of using time to determine the appropriate level of service.

Take Note of These Clinical Criteria

You can apply a code from 80403-80406 when the service has met the following clinical criteria:

• A physician or qualified healthcare professional requested the pathology clinical consultation.
• The request is related to a laboratory finding and relevant clinical information that requires extra medical judgment beyond a simple interpretation of results.
• The pathologist renders the medical judgment and reports back to the requesting clinician.

Relate The Codes to E/M Changes

These new codes are related to recent CPT^® changes to the evaluation and management (E/M) codes that other specialty physicians use to report patient visits. The new pathology clinical consultation codes allow providers to code and bill more accurately based on the complexity of the clinical problem and level of MDM. Medical documentation is required to substantiate the code selected.

For pathologists utilizing these CPT^® codes, it is important to distinguish between time versus MDM for appropriate code selection. It is up to the provider to determine if either time or MDM is most relevant to the clinical situation.

Coding by MDM: When a pathologist performs a high-intensity consultation that has a short duration, you may appropriately code the encounter with MDM. Per CPT^® guidelines, this requires you to determine the service level using two out of the following three MDM elements: the number and complexity of problems addressed; the amount and/or complexity of data to be reviewed and analyzed; and the risk of complications and/or morbidity or mortality of patient management.

You can do this by referring to the MDM table on page 626 of the CPT^® book. Remember to use this table and not the MDM table for E/M services, as the elements are different in both tables. For example, the MDM table for 80503-80506 allows you to use one to two laboratory or pathology findings to arrive at a low level of MDM for the number and complexity of problems addressed element.

Coding by time: When a time-intensive consultation occurs, then it may be more appropriate to capture the time spent with the patient using time as the criteria for code selection. Under the new code revisions, you’ll also be able to document time beyond 60 minutes using add-on code +80506.

The bottom line: CPT^® guidance instructs you that “the methodology that accounts for the most appropriate and relevant elements for a given patient encounter should be used to select the appropriate codes.” Pathologists are encouraged to review the MDM criteria as well as the time criteria to determine which code most accurately describes the service(s) provided.

For further study: CAP released a FAQ on using the codes, which you can read at https://www.cap.org/advocacy/ payments-for-pathology-services/medicare-physician-fee-schedule/implementation-tips-for-cap-developed-pathology-consult-codes-for-2022/pathology-clinical-consultation-code-frequently-asked-questions.

Stephanie Gandomi, MS, MBA, LCGC, Contributing Writer, Kailua-Kona, Hawaii