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Pathology/Lab Coding Alert

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88329: Assess Gross Exam Charge

Published on Thu May 05, 2011

Question: Sometimes our pathologist performs an exam of a kidney biopsy to ensure that the specimen contains sufficient glomeruli for further examination and diagnosis. The pathologist reports the findings to the surgeon so that he can obtain an additional biopsy, if needed. But instead of our pathologist performing the kidney biopsy exam, we package the biopsy and send it to an outside lab for analysis. Can we charge for a gross exam and an intraoperative consult?Texas SubscriberAnswer: No, you should not charge for both a gross exam (88300, Level I -- Surgical pathology, gross examination only) and an intraoperative consultation (88329, Pathology consultation during surgery). You should code the case as 88329. When the pathologist examines the renal biopsy intraoperatively, the work typically involves a gross exam as well as low-magnification inspection to determine if the specimen contains cortex and/or medulla. This is crucial to the value of the biopsy for [...]
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