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Pathology/Lab Coding Alert

Unravel Pathology Consultations Crazy Quilt of Codes

Published on Sun Jun 01, 2003

All consultations are not created equal. Even abiding by the three R's (request, report, and render opinion) won't lead you to the correct codes for a pathologist's consultation. You also have to know the answer to the two W's what and when.

"Three distinct code families describe pathology consultations," says Kenneth Wolfgang, MT (ASCP), CPC, CPC-H, director of coding and analysis for National Health Systems Inc., a coding consultation company in Camp Hill, Pa. You can get to the right page in the CPT book if you answer these two questions:

1. What does the physician request a consult for a clinical laboratory test or anatomic pathology assessment?

2. When does the pathologist consult with the physician following initial abnormal findings or as the primary analysis during surgery?

Once you're on the right page, learning the nuances of each code family is easy, then you're on your way to correct pathology consultation coding.

Know Clinical Pathology Consultation Rules

One set of codes for pathology consultations is CPT 80500 (Clinical pathology consultation; limited, without review of patient's history and medical records) and 80502 (... comprehensive, for a complex diagnostic problem, with review of patient's history and medical records). The breadth of the assessment distinguishes the two codes, with 80502 reserved for cases requiring the pathologist's full review of patient history and records.

You know that these are the proper consultation codes when you have the following answers to the two W's:

1. What the physician requests a consultation for a clinical lab test result.

2. When the consultation follows an abnormal test finding.

Only report the clinical pathology consultation when you meet the following criteria, according to Section 15020-D of the Medicare Carriers Manual (MCM):

  • 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 consultant 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 in view of the patient's condition.

    "Don't confuse this service with the physician interpretation of a clinical lab test," Wolfgang says. Medicare has designated 18 lab tests as having a professional interpretation component that it will reimburse under the Physician Fee Schedule. Included are hemoglobin electrophoresis (83020), molecular diagnostics (83912), protein electrophoresis and Western Blot (84165, 84181, 84182), immunoelectrophoresis (86320-86327), and fluorescent noninfectious agent antibody tests (86255, 86256). The MCM section 15020-E contains the complete list.

    To report the interpretation, the pathologist must meet the first three criteria listed above for a consultation, except that standing orders will suffice for the request. "Rather than using 80500 to report interpretation of these tests, the pathologist should bill the service using the appropriate laboratory code (for example, 83912) with modifier -26 (Professional component)," Wolfgang says.

    Medicare further restricts the use of clinical pathology consultation codes through its National Correct Coding Initiative (NCCI) edits, which pair 80500 and 80502 with about 350 lab codes to indicate that pathologist supervision is bundled with the lab test. When the pathologist legitimately provides a separate, documented  consultation according to the criteria, however, you can bill for it. Because of the NCCI edits, you will have to append modifier -59 (Distinct procedural service) if the lab test is one of those paired with 80500-80502.

    Pathology Consultation on Referred Material

    Three codes describe pathology consultations on slides or tissue referred from an outside institution: 88321 (Consultation and report on referred slides prepared elsewhere), 88323 (Consultation and report on referred material requiring preparation of slides), and 88325 (Consultation, comprehensive, with review of records and specimens, with report on referred material).

    "Like the 80500 family, these codes report ascending levels of consultation complexity," Wolfgang says. Use 88321 when the pathologist reviews previously prepared slides and 88323 when your lab must prepare slides from referred tissue before the pathologist examines them. As with 80502, only report 88325 when the pathologist reviews the full patient history such as surgical notes and oncology reports along with the tissues and slides.

    It's time to use 88321-88325 when you have the following answers to the two W's:

    1. What the physician requests a consultation for a surgical pathology or cytology case from an outside institution.

    2. When the consultation does not occur during surgery but later, following an initial diagnosis.

    "One word of caution when using the 88321-88325 codes: Unlike most other surgical pathology codes, the specimen is not the unit of service," Wolfgang says. Instead, report one unit of 88321 for one accession, which may include multiple specimens from one surgical pathology or cytology case.

    "Multiple slides or specimens from a single patient may comprise one or several accessions depending on the date the tissue or slides were originally processed and the body area from which the specimen(s) came," Wolfgang says.

    For example, you should report two units of 88321 for consultation on slides from a lesion excision taken on one date and slides from a margin re-excision taken two days later. But you should report only one unit of 88321 for consultation on slides from a hysterectomy and a separate lymph node resection taken from the same patient on the same day. Also report two consultations if the referred slides represent two different organ systems, even if originally taken on the same day. Use modifier -59 (Distinct procedural service) to indicate that you are not double-billing, but that the pathologist performed two separate consultation services.

    Understand Pathology Consultation During Surgery

    As with any consultation, the family of codes 88329- 88332 (Pathology consultation during surgery ) involves request for service, rendering of medical judgment, and report. "The specific nature of these codes is that the pathologist provides immediate feedback to the surgeon during the surgical procedure," says R.M. Stainton Jr., MD, president of Doctor's Anatomic Pathology, an independent pathology laboratory in Jonesboro, Ark.

    Report 88329-88332 when you have the following answers to the two W's:

    1. What the physician requests a consultation for a surgical pathology case.

    2. When the consultation occurs while the patient is in surgery.

    "Code 88329 (Pathology consultation during surgery) represents gross examination only," Stainton says. "We use this code when the surgeon asks for a quick look at a specimen or a margin during surgery, and the pathologist does not perform a microscopic exam."

    Report 88331 ( first tissue block, with frozen section[s], single specimen) when the pathologist consults during surgery and evaluates any number of frozen sections from a single tissue block. A block is a portion of tissue prepared for sectioning, in this case by freezing. Frozen sections are thin slices cut from the block. Because 88331 is an indented code, it includes the service listed in parent code 88329, Stainton says.

    Use 88332 ( each additional tissue block with frozen section[s]) to report the pathologist's evaluation during surgery of any number of frozen sections from a second or subsequent tissue block from the same specimen. If the pathologist consults on a separate specimen later in the same surgery, however, such as a different margin resection, report an additional 88331 for the first block from the new specimen and an additional 88332(s) for any subsequent block(s).

    In addition to the consultation during surgery, the pathologist often also performs the definitive surgical pathology examination. For example, the pathologist may examine frozen sections from a breast lesion during surgery and then provide the final diagnosis of the breast biopsy. You should report both 88331 for the frozen sections and 88305 (Level IV - Surgical pathology, gross and microscopic examination, breast biopsy, not requiring microscopic evaluation of surgical margins) for the biopsy exam.

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