Pathology/Lab Coding Alert

Question: An 80-year-old Medicare patient has an abnormal CBC (complete blood count). The WBC (white blood cell count) exceeds the labs threshold requiring review (30,000). The pathologist reviews the smear and issues a report, Lymphocytosis consistent with C.L.L., (chronic lymphatic leukemia) which is written in the chart. Can he bill for this or does he need a specific request by the attending physician?

Mississippi Subscriber

Answer: The pathologist can bill for the 85060 (blood smear, peripheral, interpretation by physician with written report) without a specific request from the attending physician. To support such billing, follow these guidelines:

1. There should be a written laboratory policy, approved by the hospital, stating that when the WBC exceeds a certain threshold, a pathologist will review the slide and issue a written report.

2. In addition to the notation in the chart, generate a separate laboratory report for the medical record.

3. Both the chart notation and the report must be authenticated, that is, signed and dated.