Pathology/Lab Coding Alert

Clinical laboratory test results often are returned as a computer-generated report or, under some circumstances, with a pathologists interpretation of those results. If more than a routine report or interpretation is called for, the pathologist may be able to capture the service as a clinical pathology consultation. If the three Rs and the four standards are met, it is a consultation.

Criteria for Clinical Pathology Consultation Codes

According to Laurie Castillo, MA, CPC, president of American Academy of Professional Coders Northern Virginia Chapter and owner of Physician Coding & Compliance Consulting in Manassas, Va., there are two codes for clinical-pathology consultations. One is for a limited service, 80500 (clinical pathology consultation;limited, without review of patients history and medical records), and one is for a more extensive service, 80502 (comprehensive, for a complex diagnostic problem, with review of patients history and medical records). These are professional-service-only codes, meaning that there is no technical component involved.

These codes are for a very specific consultation service relating to communication with an attending physician about results of clinical laboratory tests, Castillo says. As with other CPT consultation codes, certain criteria must be met and documented in the medical record for the service to be considered a consultation.

The three-R test always helps to identify a consultation:

a request (for a consultation);
a review (of an abnormal test result); and
a report (written).

These four standards offer further clarification:

1. A patients attending physician, from the same or another institution, must request the consultation. Another physician ordering the test does not constitute a request for consultation. A standing order cannot substitute for an individual physician request for Medicare patients.

2. A consultation must relate to an abnormal test result, based on the condition of the patient. In other words, the test result must be outside of the clinically significant expected range.

3. A clinical pathology consultation requires the exercise of medical judgment by the consulting pathologist. This pathologists opinion should be applicable to the attending physicians management of the patient.

4. A consultation must result in a written report that is included in the patients medical record.

Meeting the three Rs and four standards would qualify the service as a clinical-pathology consultation. According to the April 1997 issue of CPT Assistant, codes 80500-80502 should not be reported if the clinical pathologist has already performed a consultation and reported on referred material or slides (88321-88325). Finally, Castillo points out that if the pathologists consultation involves examination and evaluation of the patient, codes 99241-99275 (evaluation and management consultations) should be used.

Medicare Rules

The Health Care Financing Administration (HCFA) provides direction for these codes in the Medicare Carriers Manual section 15020. The following example is furnished there as an example of a complex consultation that should be processed under code 80502:

A pathologist telephones a surgeon about a patients suitability for surgery based on the results of clinical laboratory test results. During the course of their conversation, the surgeon asked the pathologist whether, based on test results, patient history and medical records, the patient is a candidate for surgery. The surgeons request required the pathologist to render a medical judgment and provide a consultation. The pathologist follows up his/her oral advice with a written report and the surgeon notes in the patients medical record that he/she requested a consultation.

HCFA further instructs that routine conversations between a laboratory director and an attending physician about test orders or results are not consultations unless all four requirements are met. Similarly, information that ordinarily could be furnished by a non-physician laboratory specialist will not be payable for a physician consultation. Interpretive consultations that do not require the pathologist to review the patients history and medical record should be reported with code 80500.

Remember that third-party payers and local Medicare carriers may have more specific guidance about the use of these codes, and should be consulted as the final authority, Castillo cautions. In fact, some local medical review policies (LMRPs) list clinical laboratory tests that billers might expect to be reported with a consultation code if the four criteria are met.

Clinical Example

Cory A. Roberts, MD, program director for the department of pathology and microbiology at the University of Nebraska Medical Center in Omaha, Neb., says that a pathology consultation often is called for in the case of a blood transfusion reaction. For example, if a patient receiving packed red blood cells postoperatively [36430] exhibits fever [780.6] and hives [708.9], the attending physician often would request a pathologist to consult on the matter, reports Roberts.

The first thing the pathologist will do in this case is review the patient chart, and ascertain a check for clerical errors to assure that the patient has received the appropriate blood product, continues Roberts. Next, there will be a visual check of pre- and post-transfusion blood from the patient, which simply is a gross examination. Typically, the pathologist will then evaluate the results of direct antihuman globulin test (DAT). This test is reported with 86880 (antihuman globulin test [Coombs test]; direct, each antiserum). Although it isnt done at all institutions, we typically take a culture from the bag to identify any possible source of infection. Code 87040 (culture, bacterial, definitive; blood [includes anaerobic screen]) is used to report this procedure.

In this case, the tests indicate that the patients fever was the result of a febrile non-hemolytic transfusion reaction (E934.7). Note that the E codes should never appear as a primary diagnosis on a claim form. Similarly, the hives were diagnosed as urticaria serum reaction (999.5, other serum reaction, urticaria due to serum). Based on the test results and the patient history, the pathologist will make a recommendation concerning future blood transfusions for this patient, says Roberts. This may involve precautions such as pre-medicating with an antihistamine, filtering white blood cells before transfusing, or other appropriate measures.

The pathologist makes a written report of the findings and the medical recommendation, continues Roberts. This may be a separate report or a notation in the patients medical chart. Also, the pathologist will follow the patients condition, such as temperature and vital signs, until the situation is resolved fully. The professional service the pathologist has rendered in this case is reported using code 80502 (clinical pathology consultation; comprehensive).

The pathologist fulfilled all four requirements for a pathology consultation and reviewed the patients history and medical record, which is required for coding 80502 rather than 80500. Remember, a clinical pathology consultation has to meet these stringent criteria in order to be reimbursable, advises Castillo.