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Answer: Although its true that the surgical pathology codes (88300-88309) are based on the level of physician work involved, up-coding to the next level of service is not appropriate. The higher code would misrepresent the type of work done (e.g., 88309, testis, tumor vs. 88307, testis, biopsy) and would contradict the diagnosis and surgical codes reported by the primary physician. This might lead to denial of the claim and could be considered fraudulent. Instead, the procedure should be reported with the modifier -22 (unusual procedural services). The modifier indicates that the service provided is greater than that usually required for the listed procedure.
CPT goes on to suggest that a report may also be appropriate to explain the extra work involved. Medicare will not necessarily increase payment when modifier -22 is used, and some private carriers may not recognize the modifier. Using modifier -22 gives the most accurate representation of the clinical circumstances, however, and should be employed for that reason. All claims should be submitted in writing with a cover letter and procedure note.
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