Pathology/Lab Coding Alert

Question: A physician ordered a serum alpha-fetoprotein for a hepatitis patient, and receiving abnormal results, asked for a consultation with the pathologist. The pathologist issued a report indicating the possible implications of the lab test results for liver cancer and recommending further testing. How should the lab code this case? Can the physician report a pathology consultation code for discussing the consultation results with the patient, or can only a pathologist bill that code?

Texas Subscriber

Answer: The laboratory should code the initial test as 82105 (Alpha-fetoprotein; serum). The service includes running the test and reporting the results, including the interpretation that the results lay outside the normal range.
 
For the requested consultation, the pathologist can bill 80500 (Clinical pathology consultation; limited, without review of patient's history and medical records) or 80502 (- comprehensive, for a complex diagnostic problem, with review of patient's history and medical records) depending on the complexity of the case -- probably 80500 in this instance.
 
You must fulfill the following criteria to bill 80500, according to Section 15020-D of the Medicare Carriers Manual:

 - The patient's attending physician orders the consultation, not just the underlying lab test. Medicare specifies that standing orders do not satisfy this request requirement.
 - The consulting physician must issue a written report.
 - The consultation requires the exercise of medical judgment by the consulting physician.
 - The lab test result behind the consultation must lie outside the clinically significant normal or expected range.

Pitfall: Because the National Correct Coding Initiative (NCCI) bundles 82105 with 80500 and 80502, you must override the edit pair with modifier 59 (Distinct procedural service) if the lab test and consultation occur on the same day.
 
Who bills the consultation? Regarding the last part of your question, the pathologist should bill 80500. Although CPT does not restrict the use of codes based on physician specialty, the pathologist in this case is the individual who fulfills the requirements and completes the work of the consultation.
 
The physician discusses the results with the patient, which could impact the E/M level but does not justify the physician billing an 80500 consultation.