Pathology/Lab Coding Alert

Question: We received a request for a slide consult with slides labeled S06-111A right brow, S06-111B left thigh, and S06-111C right arm. Because the slides are from three body sites but the specimen number is the same, should we code this as one slide consult or three?


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Answer: The correct code for a pathology consultation on slides prepared elsewhere is CPT 88321 (Consultation and report on referred slides prepared elsewhere).
 
Although the unit of service for surgical pathology is the specimen, the same is not true for pathology consultation on referred material.

This referral includes three distinct skin specimens taken from the same patient on the same day, based on the specimen number.

Because the specimens are all from the same body system on the same date, the referral represents only one accession or surgical case, which is the unit of service for pathology consultation codes 88321-88325. Consequently, you should only report one unit of 88321 for this case.
 
If the pathologist received specimens taken from different dates, or representing different body systems and thus different surgical cases, you could report multiple units of 88321.

Coders often find pathology consultation coding confusing because surgical pathology codes 88302-88309 (Surgical pathology, gross and microscopic examination) use the specimen as the unit of service. If the pathologist examines three separately identified skin biopsies taken from the same patient on the same day, for example, you would report three units of 88305 (Level IV--surgical pathology, gross and microscopic examination; skin, other than cyst/tag/debridement/plastic repair).
 
But if the pathologist reviews these same three specimens as a referred consultation, you should report only one unit of 88321.