Pathology/Lab Coding Alert

Question: We received a tissue block from another institution, and our pathologist stated in the microbiology section, "Trichrome stain performed at our institution shows a regenerative nodule." Is this enough documentation to bill 88321 for a consultation and 88313 for the trichrome stain?

South Carolina Subscriber

Answer: You can't report 88321 (Consultation and report on referred slides prepared elsewhere) and +88313 (Special stains [List separately in addition to code for primary service]; Group II, all other [e.g., iron, trichrome], except immunocytochemistry and immunoperoxidase stains, each) together.

Because 88321 describes a consultation on slides that someone else prepared, you can't claim the charge for preparing special stain slides (such as +88313). Your error seems to be the consultation code selection.

You state that you received a tissue block, not prepared slides. Your pathologist states in the report that your institution prepared the trichrome-stained slides. That means you should code the consultation as 88323 (Consultation and report on referred material requiring preparation of slides), not 88321.

Document carefully: The other part of your question deals with documentation, and you don't provide enough information to ensure that you can report 88323 and +88313 together for the service.

To report the consultation, you must document the three R's -- request (from treating physician), render (medical opinion), and report (findings). In addition, you must document that the specimen is from an outside institution if you're going to report any codes in the range 88321-88325.

Your report should state something like "tissue block received from XYZ hospital for consultation." That with the pathologist's statement regarding preparing and interpreting the trichrome stain should justify reporting 88323 and +88313 for the service.