Pathology/Lab Coding Alert

Question: Is a pathologist able to order additional tests on specimens submitted for gross and microscopic evaluation? I have been told that according to CMS, the patient's attending physician must send a written order to the lab for any additional testing performed on anatomic pathology specimens because the pathologist is not considered a consultant. Tennessee Subscriber Answer: Medicare does state the general policy that the treating physician must order all diagnostic tests and that the testing facility may not change the order or perform additional tests without a new order.

However, Medicare Carriers Manual Part 3, section 15021 F creates a surgical/cytopathology exception to this rule for patients who are not hospital inpatients or outpatients. The exception allows an independent-lab pathologist to perform all tests necessary for a complete diagnosis, even if some tests are not specifically requested.

Certain criteria must be met to allow the exception. First, the test must be medically necessary to reach a diagnosis, and the test results must be communicated to and used by the treating physician. The pathologist must also provide a written report explaining why the tests were necessary.

For an esophogeal biopsy specimen, for example, the pathologist may order an Alcian blue PAS stain to identify goblet cells characteristic of Barrett's metaplasia (530.2). Because this condition is present in most patients with adenocarcinoma of the esophagus, the special stain is crucial to the patient's diagnosis and would be covered even though the treating physician may not have ordered the stain. The pathologist would bill 88305 (Level IV Surgical pathology, gross and microscopic examination, esophagus, biopsy) and +88313 (Special stains [list separately in addition to code for surgical pathology examination]; Group II, all other [e.g., iron, trichrome], except immunocytochemistry and immunoperoxidase stains, each).