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Billing & Coding of Outside Pathology Consultations

by | May 30, 2022 | Articles, Essential, Lab Compliance Advisor, Reimbursement-lca

A briefing of the current requirements you can use to avoid billing and coding errors at your own lab or pathology practice.

The rules governing billing and coding of pathology consultation reports are complex and often confusing. Here’s a briefing of the current requirements you can use to avoid billing and coding errors at your own lab or pathology practice.

The 3 Possible CPT Codes

When slides or tissues are referred for professional or second opinions, three Current Procedural Terminology (CPT) codes may apply:

CPT CodeDescription
88321Consultation and report on referred slides prepared elsewhere
88323Consultation and report on referred material requiring preparation of slides
88325Consultation, comprehensive, with review of records and specimens, with report on referred material

As explained by CPT Assistant, these codes describe consultations and report on material referred from another source, i.e., another pathologist or facility. It’s appropriate to use these codes in reporting consultations provided to another pathologist in a different practice site or facility or in reporting consultations to another physician in the same facility/site on material referred from an outside source, such as review of slides from another institution prior to surgery or therapy at your facility.

Medicare requires that the consults:

  • Be requested by an attending physician;
  • Relate to abnormal or unexpected results;
  • Require the expertise of the pathology physician; and
  • Result in a written report that’s included in the patient record.

Only CPT 88323 reflects a separately reportable technical component. The other two codes reflect physician/global services only. Since the consultation must be requested by the ordering physician, a pathologist can’t “self-order” a consultation.

Depending upon the number of specimens reviewed, dates of service, and records forwarded, multiples of these codes may be appropriate, except for Medicare. A case is thought of as the sum of surgical tissue taken from a patient during an operative procedure regardless of how the laboratory accessions the material. Bone marrow consults frequently include sequential specimens with different surgical encounters/dates. Multiples of these codes may be appropriate for certain payers. (See CCI discussions below for Medicare exceptions.)

Various sources, including the American Medical Association (AMA), provide instructions for code assignment and appropriate number of units of service (UOS). Generally, these codes incorporate:

  • Obtaining and reviewing the clinical history and referral information, including the referral letter and results of additional clinical testing;
  • Reviewing the report of gross examination;
  • Communicating as necessary with referring pathologist on gross findings and block designations;
  • Interpreting the test result;
  • Comparison with previous study reports;
  • Consideration of relevant statistical variations;
  • Identification of clinically meaningful findings;
  • Determination if additional workup is necessary;
  • Any review of literature or research during examination of the test result;
  • Dictation and pathology report preparation; and
  • Report sign-out with any concurrent telephone communication with other professionals.

Code 88321

CPT 88321 is assigned when only slides of tissue and stain preparations are forwarded for review. The number of units of this code depends on accessioning dates. Example: Where a consultation request from another institution included slides from a lumpectomy and axillary lymph nodes taken on the same day, you’d report one unit of 88321. Although the pathologist reviews slides from two specimens (breast and associated lymph nodes), they represent one surgical case from the same date of service.

The AMA lists a helpful Q&A for proper use of CPT 88321: 

Question 1: If a pathologist compares slides and reports from a mastectomy performed in 1998, slides from a colectomy and liver biopsy performed in 2000, along with slides from a lymph node biopsy from a third institution for the purpose of assessing the site of origin of recurrent tumor, how should this be reported?

Answer: Consultations on slides, referred material, and record and specimen review should be reported using codes 88321-88325. These codes are reported per unit of service or surgical case. A unit of service for codes 88321-88325 is considered the surgical pathology case or cytopathology case, which can include multiple specimens for review. Code 88321 is reported for slides that are received and prepared elsewhere, and code 88323 is reported for referred material such as tissue blocks necessary for the preparation of those slides received. Since the report of the mastectomy was only of the pathological findings, code 88325 should not be reported when the review of records is limited to the pathology reports. Based on the scenario described, code 88321 should be reported because only slides were received. As stated above, a unit of service for codes 88321-88325 is defined as the surgical pathology case or cytopathology case and reported per surgical case. Therefore, code 88321 is reported three times, as three surgical/cytopathology cases were received (slides from 1998, 2000, and the third institution). The mastectomy report is not reported, as this was limited to only the pathology report.

Question 2: Is it appropriate to report CPT code 88321, when, in fact, there has already been one consult provided and billed for the same material, including a review of the pathology report?

Answer: Yes, it would be appropriate to report CPT code 88321, Consultation and report on referred slides prepared elsewhere, if the attending (requesting) physician requests the pathologist to review pathology specimens from another institution(s) and the pathologist provides that interpretation and report.

American Medical Association

Code 88323

CPT 88323 is assigned when tissue blocks are received and additional routine histologic staining or hematoxylin and eosin (H&E) stains are performed. These are typically recuts or deeper sections of tissue. The key word is “routine.” Use 88323 when the laboratory must prepare slides from referred tissue before the pathologist examines them or the previously presented slides are inadequate for diagnosis. Example: Assume a pathologist from an outside lab requests a second opinion on a hysterectomy and sends three H&E slides, one iron-stain slide, and one CD5 antibody histochemistry slide. The referring lab also sends a tissue block. The consulting pathologist examines the five submitted slides and prepares two more H&E slides from the tissue block. The pathologist issues a written report to the referring lab. In this situation, you’d report the consultation service as 88323 since the block that was referred was used to prepare additional H&E slides.

The AMA lists the following Q&A for CPT 88323:

Question: Should codes 88321 and 88323 be reported once per batch of slides received or material provided, or by the number of actual specimens provided? Or should the code be reported only once no matter how many slides are provided or amount of referred material that must be prepared?

Answer: From a CPT coding perspective, codes 88321, Consultation and report       of referred slides prepared elsewhere, and 88323, Consultation and report on referred material requiring preparation of slides, should be reported per surgical case. For example, if a single surgical case included multiple specimens for review, the appropriate consultation code would be reported only one time for review of all the specimens in that surgical case.

Special stains may be performed by the consulting pathologist when medically necessary and may be separately billed. Due to Correct Coding Initiative (CCI) edits, a -59 modifier should be added to the codes for these stains.

American Medical Association

Code 88325

CPT 88325 is reported only when the pathologist reviews the full patient history, such as surgical notes and oncology reports, along with the tissues and slides. Additional activities include reviewing the gross examination report; communicating as necessary with the referring pathologist on the gross findings and block designations; interpreting the test results; comparing the results to previous study reports; considering relevant statistical variations; identifying clinically meaningful findings; reviewing submitted radiographs and correlating them with block and section designations; determining whether additional workup is necessary; reviewing literature or research during the examination of the test results; dictating and preparing the pathology report; and communicating the results with other professionals.

A review of pathology reports only is insufficient for this code. One would not expect a pathologist to report this code with any frequency.

The AMA includes the following Q&A for CPT 88323:

Question: My pathologist has received multiple slide specimens and records that are from different areas of the body for consultation from an outside physician. Can multiple quantities be reported? For example, if a skin biopsy from the left shoulder and a skin biopsy from the back (both biopsies were performed on the same day) are submitted for consultation would code 88325 x2 be reported?

Answer: A unit of service for codes 88321-88325 is considered the surgical pathology case or cytopathology case, which can include multiple specimens for review. Therefore, if a single surgical case included multiple specimens for review, the appropriate consultation code would be reported only once for the      review of all the specimens in that surgical (or cytopathology) case.

American Medical Association

Medicare Guidelines

The CCI includes numerous edits that prevent the above three codes from being billed with numerous other codes (Proprietary Laboratory Analyses [PLA] codes, clinical consults, bone marrow interpretations, and most anatomic pathology services). This includes IHC stains and thus, the -59 modifier needs to be attached to IHC codes to allow separate payment. These codes are also associated with a Medically Unlikely Edit (MUE) of “1.”

The CCI manual indicates that “CPT codes 88321-88325 describe surgical pathology consultation services to review slides, tissues, or other material obtained, prepared, and interpreted at a different location by a different pathologist and referred to another pathologist for a second opinion. These codes shall not be reported by pathologists reporting a second opinion on slides, tissue, or other material also examined and reported by another pathologist in the same provider group…CPT codes 88321-88325 are reported with one unit of service regardless of the number of specimens, paraffin blocks, stained slides, etc.”

“CMS payment policy,” the CCI manual adds, “allows only one unit of service for CPT codes 88321, 88323, and 88325 per beneficiary per provider/supplier on a single date of service. Providers/suppliers shall not report these codes on separate lines of a claim using CPT modifiers to bypass the MUEs for these codes.”

In addition, the CCI program includes edits to prevent billing one of these codes with another. Guidelines advise that when “reporting CPT codes 88321-88325, providers/suppliers shall not report other pathology CPT codes such as 88312, 88313, 88187, 88188, 88189, 88342, 88341, 88344, etc., for interpretation of stains, slides or other material previously interpreted by another pathologist. CPT codes 88312, 88313, 88342, 88341, and 88344 may be reported with CPT codes 88321- 88325 only if the physician performs these staining procedure(s) and interprets these newly stained slide(s). CPT code 88323 may be reported for consultation and report on referred material if the physician performs additional necessary de novo routine staining (e.g., hematoxylin-eosin, giemsa) on additional slides.”

Depending upon the circumstances, “de novo” preparations would lead to coding with CPT 88323 versus 88321.

The pathology written response should identify the date of the consult (usually date performed versus date of request), document what material was received and the manner of receipt, describe what was performed on the material, any special stains or “recuts” and their clinical application, and document other pathology reports or medical records received and reviewed with dates of service.

Diana W. Voorhees is principal in DV & Associates, Inc., Salt Lake City, UT, which makes no representation, guarantee or warranty, expressed or implied, that the information provided is free of error, and will bear no responsibility or liability for results or consequences of its use.

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