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Pathology/Lab Coding Alert

You Be The Coder:

Don't Use Surgical Pathology Codes

Published on Tue May 25, 2004

Question: When our pathologist receives a surgical pathology case for a second opinion, how should we bill it? Should we code based on the type of surgical pathology specimen just as we would if our pathologist were the first to examine the case?   

Ohio Subscriber

Answer: You should not report this service as a surgical pathology exam, based on specimen type. When another pathologist refers a case for a consultation, the service your pathologist performs is not a repeat of the surgical pathology gross and microscopic examination (88302-88309).

Your pathologist's exam in these situations is a "pathology consultation on referred material." Depending on whether your pathologist prepares slides and/or reviews patient records beyond the referring physician's pathology report, you should report one of the following three codes:

  •  CPT 88321 -- Consultation and report on referred slides prepared elsewhere
  •  CPT 88323 -- Consultation and report on referred material requiring preparation of slides
  •  CPT 88325 -- Consultation, comprehensive, with review of records and specimens, with report on referred material.

    As with any consultation, your pathologist must meet the "Three R's" to be able to bill these codes: The ordering physician Requests a consultation; the consulting physician Renders a medical opinion; the consulting physician issues a Report.

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