Pathology/Lab Coding Alert

Question: Our lab sometimes performs tests a day or more after the specimen was collected. In fact, some of the tests require multiple days to carry out (such as cultures), or occur only after another test is completed (such as susceptibility tests). Occasionally, the pathologist reviews cytology or histology slides that have been stored for months or years. What date of service should we report for all of these cases?

Colorado Subscriber

Answer: In most cases, you should report the date of service as the date that the physician or other practitioner collected the specimen. As you mention, certain tests don't accommodate the date of collection very easily, such as susceptibility tests (87181-87190, Susceptibility studies, antimicrobial agent ) that the lab may run on culture isolates several days after the original specimen collection. Despite the difficulty, the person obtaining the specimen must furnish the date of collection to the lab, and the lab must use that information as the date of service for subsequent tests run on the specimen.

The one exception to the rule is the example you gave concerning review of archived cytology or histology. You should not report the original date of specimen collection as the date of service in these cases. Instead, you should report the date that the pathologists obtained the slides from the archives. CMS outlines these guidelines in program memorandum AB-02-129 to implement its final rule for clinical diagnostic laboratory services (available on the Internet at http://www.cms.gov/manuals/pm_trans/AB02129.pdf).