Pathology/Lab Coding Alert

Question: If a pathologist receives a case from an outside facility for a patient undergoing surgery at the pathologist's facility on the same day, can we bill for the slide review? What if the pathologist is simply comparing the slides to the surgical specimen received on the same day?

Michigan Subscriber

Answer: If the pathologist performs both a slide consultation on material referred from an outside facility and a surgical pathology examination of a different specimen submitted on the same day, you can separately report each service.
 
You should code the slide consultation as CPT 88321 (Consultation and report on referred slides prepared elsewhere). Remember that to use this code, you must satisfy the "three R" consultation requirements: request, render and report. In other words, the ordering physician must request the consultation, the pathologist must render a medical opinion, and the pathologist must issue a written report.
 
Report the surgical pathology examination using the appropriate code from the 88302-88309 section, depending on the specimen type. For example, if the pathologist examines a breast biopsy, report 88305 (Level IV - Surgical pathology, gross and microscopic examination, breast, biopsy, not requiring microscopic evaluation of surgical margins). 
 
Because the NCCI edits bundle consultation code 88321 with surgical pathology examination codes 88302-88309, you'll have to use modifier -59 (Distinct procedural service) to indicate that the pathologist performed two separate services on two separate specimens.