Pathology/Lab Coding Alert

Question: Several of the pathologists within our group recently submitted reports without a detailed microscopic section, just the word done or performed in that section. Most of these reports are for low-level cases, such as gallbladder removal, hernia repairs and simple skin biopsies, occasionally with a removal of a uterus, with or without ovaries and tubes.

If the pathology report contains a detailed gross description, no detailed microscopic description other than done or performed and a final or complete diagnosis, is this considered a complete medical record? If audited by a governmental payer would this report be able to substantiate what was coded and paid?

California Subscriber

Answer: You dont indicate what code(s) you are referring to, so I am going to assume that your question is in reference to surgical pathology codes 88302 (level II, surgical pathology, gross and microscopic examination) through 88309 (level VI, surgical pathology, gross and microscopic examination).

The provisions for this code group include accession, examination and reporting. The examination stipulates only that a gross and microscopic examination is performed. The reporting guidelines are unspecified in terms of what information must be reported. The guidelines generally mean that a written text, authenticated by a pathologist, is sent to the ordering physician. The content is not defined. Therefore, if the criterion of a written report that is authenticated by a pathologist is provided, you have met the guidelines and the report will substantiate what was coded and paid.