Surgical Pathology Coding I Pathology Consultation Coding I

Описание: Consultation: A physician (or other appropriate source) requests another physician (or appropriate source) to evaluate a patient's specific problem or condition and render an opinion. The request can be written or verbal; if verbal, the request must be documented in the patient's medical record.

Pathology consultation codes are used when tissue samples are sent from another lab or pathologist for a second opinion (80500-80502).

Code 80500 is used when only the specimen is reviewed.

Code 80502 is used when clinical information is sent along with the specimen so the patient's history, treatments, and other medical information can be taken into consideration as part of the review.

Tissue removed during a biopsy/surgery is sent to a pathology laboratory, where it is sliced into thin sections for viewing under a microscope. This is known as histologic (tissue) examination and is usually the best way to tell if cancer is present. 
88300 – 88309 : Microscopic examination of specimens.
88329-88334 : Intraoperative consultations are performed during operative sessions.
88311-88325,88341-88399: This section includes codes for special treatment of specimens including special stains and decalcification of specimens.


The unit of service for CPT codes 88300 - 88309 is the SPECIMEN.
A specimen is defined as tissue(s) that is/are submitted for individual and separate attention, requiring individual examination and pathologic diagnosis. Two or more such specimens from the same patient (eg, separately identified endoscopic biopsies, skin lesions, etc.) are each appropriately assigned an individual code reflective of its proper level of service.
Code 88300 is used when only gross examination is needed without microscopic examination; all other codes require both gross and microscopic examination.
The type of specimen, including how the specimen was obtained, determines the code to be selected
For example,
a colon biopsy is assigned to Level IV (88305)
a colon segmental resection for a condition other than a tumor is assigned to a Level V (88307)
a colon segmental resection for tumor is assigned to a Level VI (88309)