Pathology/Lab Coding Alert

Question: We received slides from an outside institution that are from three separate cases, have three separate accession numbers and are from three separate dates of service. Should we bill 88321 x 3?

Nebraska Subscriber

Answer: Yes, you can bill three units of 88321 (Consultation and report on referred slides prepared elsewhere) -- for some payers. The unit of service for "outside" consultations such as 88321 is not the specimen. CPT Assistant, Dec. 2002 states, "[The] unit of service for codes 88321-88325 is considered the surgical pathology case or cytopathology case, which can include multiple specimens for review."

Understand 'case': The "case" often links to the "accession" from the referring lab. So a case typically includes all tissue or cytology specimen(s) taken during a single operative session. Having different dates of service is a clear indicator that you're dealing with separate cases. In your question, you have three separate cases (accessions, dates of service), meaning that you can report 883231 x 3 based on AMA guidelines. Many payers accept billing in this manner.

Medicare is different: As of Oct. 1, 2007, CMS limits you to billing only one unit of 88321 for the same patient on the same day, regardless of the number of specimens or separate outside cases that your pathologist examines.

The Correct Coding Initiative (CCI) policy manual states, "CMS payment policy allows only one unit of service for CPT codes 88321, 88323, and 88325 per beneficiary per provider on a single date of service. Providers should not report these codes on separate lines of a claim utilizing CPT modifiers to bypass the MUEs [medically unlikely edits] for these codes."

Other outside consults are similar: In addition to 88321, CPT provides two other outside consult codes, as follows:

• 88323 -- Consultation and report on referred material requiring preparation of slides
• 88325 -- Consultation, comprehensive, with review of records and specimens, with report on referred material.

The unit of service rules for these codes are similar to 88321, with Medicare restricting the use to once per day. Further, CCI edits prohibit reporting any of these codes together.