Pathology/Lab Coding Alert

Question: Our pathologists often evaluate frozen sections intraoperatively to provide a working diagnosis to the surgeon while the patient is still in the operating room (OR), which we report with 88331 and 88332. If bony tissue is involved, however, the pathologist may perform a tissue imprint and stain rather than a frozen, but still give results to the surgeon in the OR. How should we report that service? Can we report the imprint and a surgical consultation even though the pathologist did not look at frozen sections?

Kentucky Subscriber

Answer: The appropriate code for the tissue imprint, or touch prep, is 88161 (Cytopathology, smears, any other source; preparation, screening and interpretation). If the pathologist reports back to the surgeon in the OR, you should also report the consultation as 88329 (Pathology consultation during surgery). Use this code for intraoperative pathology consultations that do not involve frozen sections. You should never report it in addition to the frozen section codes (88331, first tissue block, with frozen section[s], single specimen; and 88332, each additional tissue block with frozen section[s]) because it is the parent code, meaning the consultation is bundled with the frozens. But CPT does not bundle the consultation with the touch prep (88161), so you should bill both codes together when the pathologist provides both services.

Reader Questions and You Be the Coder were prepared with the assistance of R.M. Stainton Jr., MD, president of Doctors'Anatomic Pathology Services in Jonesboro, Ark.; and Laurie Castillo, MA, CPC, CPC-H, CCS-P, member of the National Advisory Board of the American Academy of Professional Coders and president of Physician Coding and Compliance Consulting in Virginia.