Pathology/Lab Coding Alert

Decide if you want to reward time or toil.

When your pathologist performs a pathology clinical consultation, you must choose between assigning the correct CPT^® code based on the time involved or the complexity of the case.

Read on for tips to help you decide which way to go.

Know the Basics

A pathology clinical consultation is a service provided by a pathologist in response to a request from a qualified healthcare professional. The service is a clinical evaluation and written report regarding pathology and/or laboratory findings and other relevant information that requires medical interpretive judgement, often referred to as medical decision making (MDM).

CPT^® provides the following three code choices, plus an add-on code for cases requiring an extended time investment:

• 80503 (Pathology clinical consultation; for a clinical problem, with limited review of patient’s history and medical records and straightforward medical decision making. When using time for code selection, 5-20 minutes of total time is spent on the date of the consultation.)
• 80504 (… for a moderately complex clinical problem, with review of patient’s history and medical records and moderate level of medical decision making. When using time for code selection, 21-40 minutes of total time is spent on the date of the consultation.)
• 80505 (… for a highly complex clinical problem, with comprehensive review of patient’s history and medical records and high level of medical decision making. When using time for code selection, 41-60 minutes of total time is spent on the date of the consultation.)
• +80506 (… prolonged service, each additional 30 minutes (List separately in addition to code for primary procedure)

Remember: Per CPT^®, you should always use 80506 in conjunction with 80505. And you should only use 80506 for prolonged pathology clinical consultation service of more than 15 additional minutes; clinical consultation services of less than 15 minutes are not reported separately.

Follow These Do’s and Don’ts

Do the 3Rs: To use 80503-+80506, the pathologist must document a Request for the service, Render medical judgement, and Report (written) on the findings.

Specifically, these codes should include the following elements:

• Written documentation that a physician or other qualified healthcare professional requested the service, whether the original request is written, phoned in, electronic, or face-to-face
• Documentation that the pathology clinical consultation was related to a pathology or laboratory finding and other relevant clinical information showing that the pathologist exercised MDM beyond basic interpretation of results to render a finding
• Documentation that the pathologist presented a written report to the requesting clinician

Don’t upcode: Plenty of pathology, laboratory, or other procedures may include elements of the pathology clinical consultation, so you need to take care not to apply the codes incorrectly. For instance, you should not apply an 80503-family code when:

• The pathologist is reporting lab/pathology and clinical findings without providing medical interpretative judgment
• An evaluation and management (E/M) service includes a review of pathology and laboratory test results, or the consultation involves an examination and evaluation of the patient
• Reporting 88321 (Consultation and report on referred slides prepared elsewhere), 88323 (Consultation and report on referred material requiring preparation of slides), or 88325 (Consultation, comprehensive, with review of records and specimens, with report on referred material), which describe various levels of consultation and report on referred pathology slides or material, per a CPT^® note
• A more specific code for pathology interpretation and report exists, such as 88291 (Cytogenetics and molecular cytogenetics, interpretation and report) or G0452 (Molecular pathology procedure; physician interpretation and report)

Take a Hint for Time or MDM

CPT^® guidance states that you may select the 80503-family code “based on either the total time for pathology clinical consultation services performed on the date of consultation or the level of medical decision making as defined for each service.” In other words, the provider can decide whether to code based on time or MDM.

How do you decide? The first step is to understand the criteria from the CPT^® Pathology MDM Table, as well as the time ranges for each code and what items count toward time. You’ll read about that information in the following sections.

But remember: You can report code +80506 only in addition to code 80505 if you’ve selected to code the encounter based on time, not MDM. Once you understand the criteria, you may want to select the appropriate code by time for a time-intensive pathology clinical consultation, or by MDM for a brief consultation involving a complex level of MDM.

See What Counts Toward Time

For pathology clinical consultation services, the time is the total time the pathologist personally spends on the date of the consultation. You should count only time in activities required for a consultation, not normal clinical-staff activity.

CPT^® instruction states, “Consultant time includes the following activities, when performed:

• “Reviewing available medical history, including presenting complaint, signs and symptoms, personal and family history
• “Reviewing test results
• “Reviewing all relevant past and current laboratory, pathology, and clinical findings
• “Arriving at a tentative conclusion or differential diagnosis
• “Comparing findings against previous study reports, including radiographic reports, images as applicable, and results of other clinical testing
• “Ordering or recommending additional or follow-up testing
• “Referring and communicating with other QHPs [qualified healthcare providers] (not separately reported)
• “Counseling and educating the physician or other QHP
• “Documenting the clinical consultation report in the electronic or other health record”

Key: You must document the time in the medical record.

For prolonged services when coding by time, you would report 80505 plus 1 unit of +80506 for each additional 30 minutes beyond 60 minutes.

Caveat: If you have less than 15 minutes of additional time (that is, total time less than 75 minutes), you should not list the add-on code.

Master MDM Criteria

CPT^® provides an MDM table specifically for pathology clinical consultations that identifies the codes based on two out of three elements:

• Number and complexity of problems addressed
• Amount and/or complexity of data to be reviewed and analyzed
• Risk of complications and/or morbidity or mortality of patient management

For instance: The table states that a low “number and complexity of problems addressed” would involve one or two laboratory or pathology findings or two or more self-limited problems.

Using the criteria in the table, CPT^® assigns 80503 to a low level of MDM, 80504 to a moderate level of MDM, and 80505 to a high level of MDM. If you’re coding by MDM, you cannot report +80506.

Caution: Make sure you use the pathology MDM table, not the E/M MDM table, when using codes 80503-80505.

Ellen Garver, BS, BA, Contributing Writer