Pathology/Lab Coding Alert

Question: When we have a request for interpretation on a molecular pathology test in our lab, the lab director evaluates and writes the report on the test results in question. He is not a physician, but holds a PhD. Can we bill G0452 for the interpretation? If not, can we bill 88291?

Codify Subscriber

Answer: Based on the information you provided, billing 88141 (Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician) in this case is not appropriate.

To bill 88141 in addition to the code for the technical Pap test, you must fulfill the following criteria:

• The cytotechnologist finds or suspects an abnormality or judges that a pathologist’s interpretation is needed
• The pathologist evaluates the smear
• The pathologist makes a written report of findings

Your statement that the test “is always reviewed by a pathologist,” could fit the description of the technical Pap test code, such as 88175 (Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening or review, under physician supervision) with the pathologist doing the manual review or performing “under physician supervision,” neither of which fits the 88141 definition.