Pathology/Lab Coding Alert

When material is referred from another pathologist or facility, the use of CPT codes 88321-88325 (consultation and report on referred material) may seem straightforward. But these codes often are used improperly by pathologists and coders, according to Peggy Slagle, CPC, billing compliance coordinator for the Department of Pathology and Microbiology at the University of Nebraska Medical Center in Omaha, Neb.

This is a big issue for us, reports Slagle, because as a university lab, we do a lot of consultations and often receive material from other laboratories for deemed opinions. Although the specimen is the unit of service for most surgical pathology codes, accession is the unit of service for consultation codes 88321-88325.

Code Consultations Per Accession

Whether the lab receives referred slides (88321) or referred tissue requiring preparation of slides (CPT 88323 ), the service should be billed on a per accession basis. Accession simply means an item added. But for a pathology lab , does that mean each slide or each box of slides? Does it mean each container of tissue? Is an accession all material relating to a patient that is referred to your lab on a given day?

Multiple slides or specimens from a single patient may comprise one accession, or they may represent several accessions that are separately identified and included in a single report, says Slagle. The key to defining accession is the date the tissue or slides were originally processed, and the area of the body the specimen(s) came from, she continues. For example, if a patient had a skin lesion removed that was later reported malignant, with margins not clear, an excision may have been scheduled for a later date. These two sets of slidesone from the original excision and one from the re-excisionwere referred to a pathologist for a consultation. If we received slides dated Oct. 10, 1999, and additional slides from the same patient dated Oct. 12, 1999, we would code for two consults (88321), says Slagle. They are considered two accessions because of the different dates on the slides.

Ken Wolfgang, MT (ASCP), CPC,CPC-H, president and CEO of Kenneth E. Wolfgang, Inc., Health Services Consulting in Portland, OR, a coding consultation company focusing on hospital pathology labs, agrees. Aside from date of sample, different geography on the body is another criterion for determining accession, he says. If tissues taken from two different organ systems in the same patient on the same date are submitted to the lab for a consultation, they are considered two accessions. For example, if tissue from a rectal carcinoma (154.1, malignant neoplasm of rectum) is referred along with tissue from a distinct neoplasm of the cervix (179, malignant neoplasm of uterus, part unspecified), the pathologist should code for two distinct consultations (88323), he says.

But the referral of multiple specimens does not always mean multiple accessions. For example, slides from a radical hysterectomy that include different lymph node groups and peritoneal tissue would be coded once as 88321. The procedure would be considered one accession because the multiple slides from related tissues point to a single disorder of one organ.

One common situation experienced by pathologists concerns tissue submitted to determine whether there is a recurrence of a cancer. A lab may receive slides from one patient that include a colon tumor removed two years ago and a current biopsy of the gall bladder. The pathologist is asked to analyze the slides to see if the new tumor is a recurrence. This work would constitute two accessions and should be coded 88321 twice.

Consultation Requirements

Remember that codes 88321-88325 require the pathologist to generate a report and are only used for consultation on material referred from another source, says Wolfgang.

That means:
1) consultations to a pathologist at a different facility on referred material; or
2) consultations to another physician at your facility on material referred from an outside source.

The latter situation might occur when a physician at your facility is planning surgery but has slides from another institution where the patient was previously treated. Keep in mind that codes 88321-88325 should not be used for a pathology consultation to an attending physician at your facility as there are other CPT codes for those services (80500, clinical pathology consultation; limited, without review of patients history and medical records, and 80502, comprehensive, for a complex diagnostic problem, with review of patients history and medical records).

Once the pathologist has established that the material is referred from elsewhere and determined the number of accessions, he or she has to decide what level of service to report. The lowest level (88321) involves a consultation and report on prepared slides that are submitted to the lab. If the lab receives tissue that requires slide preparation, 88323 is used. The highest level of service (88325, consultation, comprehensive with reviews of records and specimens, with report on referred material) is reserved for cases involving a comprehensive review of the patient record. The pathologist may review patient history, surgical notes, results of oncologists consultations and pathology reports. When only the lab reports are reviewed, 88325 is not appropriate.