Pathology/Laboratory List

Pathology/Laboratory

Chapter Topics
Format
Organ or Disease-Oriented Panels
Drug Testing Therapeutic Drug Assays
Evocative/Suppression Testing
Consultations (Clinical Pathology)
Urinalysis, Molecular Pathology, and Chemistry
Molecular Pathology
Hematology and Coagulation
Immunology
Transfusion Medicine
Microbiology
Anatomic Pathology
Cytopathology and Cytogenic Studies
Surgical Pathology Other Procedures Chapter Review Quick Check Answers
Learning Objectives
After completing this chapter you should be able to
1

Explain the format of the Pathology and Laboratory section
2
Understand the information in the Pathology and Laboratory Guidelines
3
Demonstrate an understanding of Pathology and Laboratory terminology
4
Differentiate amongst the Organ or Disease Oriented Panels codes
5
Recognize Drug Testing codes
6
Identify Therapeutic Drug Assays codes
7
Classify Evocative/Suppression Testing codes
8
Explain Consultations (Clinical Pathology) codes
9
Interpret Urinalysis, Molecular Pathology, and Chemistry codes
10
Evaluate Hematology and Coagulation codes
11
Describe Immunology codes
12
Discriminate amongst Transfusion Medicine codes
13
Interpret Microbiology codes
14
Evaluate Anatomic Pathology codes
15
Summarize Cytopathology and Cytogenic Studies codes
16
Explain Surgical Pathology codes
17
Choose Other Procedures codes
18
Demonstrate the ability to code Pathology and Laboratory services
FORMAT
The Pathology and Laboratory section of the CPT manual is formatted according to type of test performed—automated multichannel, panels, assays, and so forth
To familiarize yourself with the content of the Pathology and Laboratory section, review the subsections in the CPT manual
This will help you get a broad overview of the contents of this important section as you prepare to learn the specifics
Laboratories have built-in indicators that allow additional tests to be performed without a written order from the physician
These standards are set by the medical facility and imply that when a certain test is positive, it is assumed that the physician would want further information on the condition and specific additional tests performed
For example, if a routine urinalysis is performed, a culture is performed if the test is positive for bacteria
If a culture is performed to identify the organism, a sensitivity test is performed if the bacteria are of a certain type or count, as predetermined by the medical facility to warrant the additional laboratory studies
You will code only after the tests are performed, because an order for a laboratory test does not ensure that the test will be performed
This standard ensures that all laboratory tests performed are reported
Remember that what the physician ordered may not be all the laboratory work performed, depending on the facility’s policy concerning indicators
The services in the Pathology and Laboratory section include the laboratory tests only
The collection of the specimen is reported separately from the analysis of the test
For example, if a technician in a clinic laboratory withdraws blood by means of a venipuncture from the arm, and the blood sample was then analyzed in the laboratory, you would report 36415 for the venipuncture as shown in Fig
29-1 in addition to a code to report the test performed on the blood in the laboratory
Most Pathology and Laboratory subsections contain notes
Whenever notes are available, be sure to read them before assigning codes from the subsection because specific information pertinent to the codes is contained in these notes
ORGAN OR DISEASE-ORIENTED PANELS
The codes in the Organ or Disease-Oriented Panels subsection (80047-80076) are grouped according to the usual laboratory work ordered by a physician for the diagnosis of or screening for various diseases or conditions
Groups of tests may be performed together using automated equipment, depending on the situation or disease
For example, during the first obstetric visit, a mother is commonly asked to have baseline laboratory tests performed to ensure that appropriate antepartum care is provided
CPT code 80055 describes an obstetric panel that would typically be performed during the first obstetric visit
To assign a panel code, each test listed in the panel description must be performed
Additional tests are reported separately
The development of panels saves the facility from having to report each test separately, and it is often more economical for the patient
You cannot assign modifier -52 (reduced service) with a panel
For example, if all of the tests in the obstetric panel were done except the syphilis test, you could not report 80055 (Obstetrical Panel) with modifier -52
You would instead list each of the tests separately
CODING SHOT
Be careful when coding multiple panels on the same day for the same patient
Sometimes several panels include some of the same tests
For example, a hepatitis B surface antigen test is included in both the obstetric panel and the acute hepatitis panel
It would be inappropriate to report the same test twice
The laboratory and pathology reports in the patient medical record will describe the method by which the test was performed
There are many different methods of performing the same test
For example, a urinalysis can be automated or nonautomated and can include or exclude microscopy
It is necessary to know these details if you are to assign the correct urinalysis code
If the details you need are not in the medical record, ask the laboratory staff or physician for further clarification
DRUG TESTING
Laboratory drug testing (80100-80104) is performed to identify the presence or absence of a drug
Testing that determines the presence or absence of a drug is qualitative (the drug is either present or not present in the specimen)
When the presence of a drug is detected in the qualitative test, a confirmation test is usually performed by using a second testing method
Code 80102 is used to report a confirmation test
Codes from the Therapeutic Drug Assay and Chemistry subsections are used to further identify the exact amount of the drug that is present (quantitative)
For example, a patient who has been on a medication for a long time might need to undergo testing to determine whether the drug level is at the correct therapeutic level
The CPT manual lists the drugs most commonly tested for, although the use of the codes is not limited to the drugs listed
Modifier -51 is not assigned to pathology or laboratory codes
instead, each test is listed separately
For example, if a confirmation test was conducted for both alcohol and cocaine, report 80102 twice and append modifier -91, repeat clinical diagnostic laboratory test, to the second code
Therapeutic Drug Assays
Drug assays (80150-80299) test for a specific drug and for the amount of that drug
Many types of drugs are listed in this subsection
If the drug is not listed, it is possible that quantitative analysis may be listed under the methodology (e
g
, immunoassay, radioassay)
Therapeutic drug assays are performed to help the physician monitor the level of medication in the patient’s system or to monitor the patient’s compliance
For example, levels may be measured to make certain the patient is getting the correct level of antibiotics
Blood specimens for drug monitoring are usually taken during the drug’s highest therapeutic concentration (peak level) and at the drug’s lowest therapeutic concentration (trough or residual level)
Peak and trough levels should be within the therapeutic range directed by the physician
The drugs are listed by their generic names, not their brand names
For example, 80152 describes the generic drug amitriptyline, also sold under the brand names of Elavil and Endep
A Physician’s Desk Reference that lists pharmaceuticals by the generic and brand name will be helpful as you code drug testing and assays
One location of Drug Testing codes in the index of the CPT manual is under the main term “Drug,” subtermed by the reason for the tests—analysis or confirmation
Therapeutic Drug Assay subsection codes can be found under the main term “Drug Assay” and subterms of the material examined, for example, amikacin, digoxin
EVOCATIVE/SUPPRESSION TESTING
Evocative/Suppression (80400-80440) testing is performed to measure the effect of evocative or suppressive agents on chemical constituents
For example, 80400 is reported when a patient undergoes testing to determine whether adrenocorticotropic hormone (ACTH) is being produced in the body
The patient may have adrenal gland insufficiency
Note that following each of the code descriptions is a statement of the services that must have been provided for the code to be reported
For example, the requirement to report 80400 ACTH stimulation panel is “Cortisol (82533 3 2)” or two cortisol tests were performed
Code 80400 bundles two units of 82533 into one code
Before you can assign 80400, however, you must read the code description for 82533 to ensure that the code reports the correct test
CAUTION
Remember that the codes from the Pathology and Laboratory section are only for the tests performed and do not reflect the complete service provided to the patient
To code the components of Evocative/Suppression Testing consider the following:
n
If the physician supplied the agent, report the supply using 99070 from the Medicine section or a HCPCS code
n
If the physician administered the agent, report the infusion or injection with codes 96365-96379 from the Medicine section
n
If the test involved prolonged attendance by the physician, report the service with the appropriate E/M code
CONSULTATIONS (CLINICAL PATHOLOGY)
A clinical pathologist, upon request from a primary care physician, will perform a consultation to render additional medical interpretation of test results
For example, a primary care physician reviews lab test results and requests a clinical pathologist to review, interpret, and prepare a written report on the findings, which represents a clinical pathology consultation
There are two codes under the subsection Consultations (80500, 80502)
These consultations are based on whether the consultation was limited or comprehensive
A limited consultation is one that was done without the pathologist’s review of the medical record of the patient, and a comprehensive consultation is one in which the medical record was reviewed as a part of the consultative services
When either of these consultation codes is submitted to a third-party payer, the submission is accompanied by a written report
These are not the only consultation codes in the Pathology and Laboratory section of the CPT manual
There are also consultation codes toward the end of the section in the Surgical Pathology subsection (88321- 88334) that report the services of a pathologist who reviews and gives an opinion or advice concerning pathology slides, specimens, material, or records that were prepared elsewhere or for pathology consultation during surgery
Pathology consultations during surgery are provided to examine tissue removed from a patient during a surgical procedure
If the pathologist did not use a microscope to examine the tissue, report 88329
If a microscope was used to examine the tissue, report 88331 or 88332, depending on the number of specimens that were examined
A specimen is a sample of tissue from a suspect area
a block is a frozen piece of a specimen
and a section is a slice of a frozen block
A pathologist prepares a specimen by cutting it into blocks and taking sections from the blocks
The preparation of a frozen section is illustrated in Fig
29-2
The number of sections taken depends on the judgment of the pathologist as to the number of areas of the specimen that need to be examined
The frozen section is placed (mounted) on a slide or held by other means that allow the pathologist to view the tissue under a microscope
CODING SHOT
Each specimen may be reported separately, but each slide from that specimen may not
CMS RULES
The edits bundle 88329 (pathology consultation during surgery) with 88331 (first tissue block) and 88332 (each additional tissue block)
By issuing this guideline, CMS includes the frozen sections in the consultation bundle, which would usually be reported separately
When one block is sectioned and examined, the service of examining that first section is reported using 88331
The second and subsequent sections of the same block are included in the reporting of 88331
If another block from another area (a second block) was sectioned, the first section would be reported using 88331, and subsequent sections from the second block using 88332
You cannot use 88332 without first reporting 88331
Although 88332 is not marked as an add-on code (one that is used only with another code), its function is that of an add-on code because it is for subsequent sections that were examined
URINALYSIS, MOLECULAR PATHOLOGY, AND CHEMISTRY
Many types of tests are located under the Urinalysis and Chemistry subsections (81000-84999)
Urinalysis codes are for nonspecific tests performed on urine
Chemistry codes are for specific tests performed on material from any source (e
g
, urine, blood, breath, feces, sputum) (Fig
29-3)
For example, a urinalysis using a dipstick (81000-81003) would report the presence and quantity of the following constituents: bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, and urobilinogen
Any number of these constituents may be analyzed and reported using a code from the Urinalysis subsection (81000-81099)
However, if the physician ordered an analysis of the urine specifically to determine the presence of urobilinogen (reduced bilirubin) and the exact amount of urobilinogen present (quantitative analysis), you would choose a code (84580) from the Chemistry subsection
The main things to remember when coding from these two subsections are:
1
Identify specific tests
2
Determine if the test was automated (by machine) or nonautomated (manual)
3
Number of tests performed
4
Identify combination codes for similar types of tests
5
Whether the results are qualitative or quantitative
6

Method of testing

MOLECULAR PATHOLOGY

The Molecular Pathology codes are divided into Tier 1 and Tier 2 codes
Tier 1 codes (81200-81383) report services for molecular assays that are more commonly performed
For example, 81211 is an essay to determine the presence of a breast cancer gene—BRCA1 (breast cancer 1) and BRCA2 (breast cancer 2)
There are many conditions in which a genetic predisposition can be predicted, such as cystic fibrosis and colon cancer
Tier 2 codes 81400-81479 involve less commonly performed analyses and are arranged by the required level of technical resources and the level of physician interpretation or other qualified health professional
HEMATOLOGY AND COAGULATION
The Hematology and Coagulation subsection contains codes (85002-85999) based on the various blood-drawing methods and tests
The method used to perform the test is often what determines code assignment
A blood count is used to measure the kind and number of cells in the blood, such as red and white blood cells
It is a commonly used test to detect various abnormalities in the blood
Blood counts can be manual or automated (Fig
29-4), with many variations of the tests
For example, codes in the range 85004-85049 are blood count codes divided by method (manual or automated) and type of count, such as white blood count (WBC, 85004-85009) or a complete blood count (CBC, 85025, 85027)
To accurately code a blood count, the method and the type of the count must be documented
There are codes within the Hematology and Coagulation subsection for blood smear and bone marrow smear interpretations (85060, 85097)
When a physician procures the bone marrow by means of aspiration, the service is reported with a code from the Surgery section (38220)
but that is only part of the service
The other part of the service is the pathology analysis of the aspirated specimen
As the coder in a clinic setting, you may be reporting only the surgical services or only the pathology/laboratory services or a combination of both
When reporting the surgical services, always review the pathology report as a part of the code assignment, and when reporting the pathology services, always review the operative report
There are many blood coagulation tests located in the Hematology and Coagulation subsection
The codes are divided based on the particular factor being tested
Great care must be taken to ensure that the correct coagulation factor has been reported based on the information in the medical record
Coagulation factor tests analyze the level of certain proteins in the blood that enable the blood to congeal properly
Low levels of a factor may
result in excessive bleeding and high levels may lead to clot formation (thrombosis)
For example, 85610 reports a test to assess the level of factor II (also known as a prothrombin)
This test is often performed when a patient is on a blood thinning medication and the physician wants to determine if the factor is at the optimal level
Most of the tests in the Hematology and Coagulation subsection can be located in the index of the CPT manual under the name of the test, such as prothrombin time, coagulation time, or hemogram
As you can see, there are many variations of just a blood count test! Read the medical record and code descriptions carefully before assigning the codes
IMMUNOLOGY
Immunology codes (86000-86804) report identification of conditions of the immune system caused by the action of antibodies (e
g
, hypersensitivity, allergic reactions, immunity, and alterations of body tissue)
TRANSFUSION MEDICINE
The Transfusion Medicine subsection codes (86850-86999) report tests performed on blood or blood products
Tests include screening of blood (Fig
29-5) for antibodies, Coombs testing, autologous blood collection and processing, blood typing, compatibility testing, and preparation of and treatments performed on blood and blood products
Transfusion of blood and blood components is reported with codes from a variety of locations
For example, to report the actual blood transfusion, assign 36430 from the Surgery section of the CPT manual
You must also report the substance being transfused, such as whole blood, HCPCS code P9010 per unit or red blood cells, P9021 per unit
The blood bank would provide and report the collection, processing, and storing of the autologous blood with 86890
MICROBIOLOGY
Microbiology codes (87001-87999) report the study of microorganisms and include bacteriology (study of bacteria), mycology (study of fungi), parasitology (study of parasites), and virology (study of viruses)
For example, Fig
29-6 illustrates a Petri dish used to culture microbes
Culture codes for the identification of organisms as well as the identification of sensitivities of the organism to antibiotics (called culture and sensitivity) are located in this subsection
Culture codes must be read carefully because some codes report screening only to detect the presence of an organism
some codes indicate the identification of specific organisms
and others indicate additional sensitivity testing to determine which antibiotic would be best for treatment of the specified bacteria
You report all tests performed on the basis of whether they are quantitative or qualitative and/or a sensitivity study
ANATOMIC
PATHOLOGY
Anatomic Pathology codes (88000-88099) report examination of body fluids or tissues in postmortem (after death) examination
Postmortem examination involves the completion of gross, microscopic, and limited autopsies
Codes are divided according to the extent of the examination
This subsection also contains codes for forensic examination and coroner’s call
For example, some codes report an examination without the central nervous system (88000, 88020), with the brain (88005, 88025), with the brain and the spinal cord (88007, 88027), etc
There are two codes for each extent because one is a gross examination and one is a microscopic examination
CYTOPATHOLOGY AND CYTOGENIC STUDIES
The Cytopathology subsection codes (88104-88199) report the laboratory work performed to determine whether cellular changes are present
For example, a very common cytopathology procedure is the Papanicolaou smear (Pap smear)
Cytopathology may also be performed on fluids that have been aspirated from a site to identify cellular changes
Cytogenetic Studies (88230-88299) include tests performed for genetic and chromosomal studies
SURGICAL PATHOLOGY
Surgical Pathology codes (88300-88399) describe the evaluation of specimens to determine the pathology of disease processes
When choosing the correct code for pathology, identify the source of the specimen and the reason for the surgical procedure
The Surgical Pathology subsection codes are divided into six levels (Levels I through VI) based on the specimen examined and the level of work required by the pathologist
Pathology testing is performed on all tissue removed from the body
The surgical pathology classification level is determined by the complexity of the pathologic examination
Level I pathology code 88300 identifies specimens that normally do not need to be viewed under a microscope for pathologic diagnosis (e
g
, a tooth)—those for which the probability of disease or malignancy is minimal
Level II pathology code 88302 deals with those tissues that are usually considered normal tissue and have been removed not because of the probability of the presence of disease or malignancy, but for some other reason (e
g
, a fallopian tube for sterilization, foreskin of a newborn)
Level III pathology code 88304 is assigned for specimens with a low probability of disease or malignancy
For example, a gallbladder may be neoplastic (benign or malignant), but when the gallbladder is removed for cholecystitis (inflammation of the gallbladder), it is usually inflamed from chronic disease and not because of cancerous changes
Level IV pathology code 88305 designates a higher probability of malignancy or decision making for disease pathology
For example, a uterus is removed because of a diagnosis of prolapse
There is a possibility that the uterus is malignant or that there are other causes of disease pathology
Level V pathology code 88307 classifies more complex pathology evaluations (e
g
, examination of a uterus that was removed for reasons other than prolapse or neoplasm)
Level VI pathology code 88309 includes examination of neoplastic tissue or very involved specimens, such as a total resection of a colon
For example, 88305 reports examination of tissue from a breast biopsy that does not require microscopic evaluation of the margins or tissue from a breast reduction
88307 reports examination of tissue from the excision of a breast lesion that does require microscopic evaluation of the margins and a partial/simple mastectomy
and 88309 reports examination of tissue from a mastectomy with regional lymph node
The probability of cancer increases with each code
The remaining codes at the end of the subsection classify specialized procedures, utilization of stains, consultations performed, preparations used, and/or instrumentation needed to complete testing
The surgical pathology codes are located in the index under the main term “Pathology” and subterms “Surgical” and “Gross and Micro Exam

CODING SHOT
A specimen is defined as tissue submitted for examination

If two specimens of the same area are received and examined, each specimen is reported
For example, if two separately identified anus tags are received and each is examined, report 88304 3 2
If one anus tag is received and two different areas of the tag are examined, report 88304 only once
OTHER PROCEDURES
Other Procedures includes miscellaneous testing on body fluids, the use of special instrumentation, and testing performed on oocytes and sperm
STEP BY STEP BOOK I
COMPLETEDINTRO TO CPT CODING BOOK IIChapter 6
Pathology and Laboratory
Chapter Objectives
Understand the Pathology and Laboratory guidelines
Understand the difference between drug testing and organ or disease-oriented panels
Recognize the differences in the Pathology and Laboratory sections
Introduction
This chapter reviews the Pathology and Laboratory section of the CPT® codebook

The 80000 series of codes is for reporting the performance of the specific laboratory test only and does not include the collection of the specimen itself via venipuncture, arterial puncture, lumbar puncture, or other collection methodology
The collection of the specimen by venipuncture or by arterial puncture is not considered an integral part of the laboratory procedure(s) performed and therefore may be reported separately
Just as throughout the CPT codebook, there are parenthetical notes following some of the codes, instructing which codes may not be reported in conjunction with that code, as well as instructing on which other codes should be reported for certain procedures
Pathology and Laboratory Guidelines
Just as with all the sections in the CPT codebook, the Pathology and Laboratory Guidelines are located in the beginning of the Pathology and Laboratory section
When performing separate procedures or multiple procedures, it is appropriate to select the multiple procedure codes that are performed on the same date of service and list the codes as separate entries on the claim form
In order to show that a laboratory procedure was repeated or that different laboratory procedures were done on the same date of service for the same patient, you may need to append the appropriate modifiers (see Chapter 10, Modifiers)
Just as with the Surgery, Radiology, and Medicine sections of the CPT codebook, the Pathology and Laboratory section has codes for unlisted services or procedures
Due to advances in the field of medicine, there may be services or procedures performed by physicians that have not yet been designated by a specific CPT code
Please note, as listed in the “Instructions for Use of the CPT Codebook” in the Introduction of the CPT codebook, it is very important that a code similar to the actual procedure performed not be selected in lieu of an unlisted procedure code
If no such specific code exists, then report the service using the appropriate unlisted procedure or service code
Any service or procedure should be adequately documented in the medical record
When reporting an unlisted code to describe a procedure or service, it may be necessary to submit supporting documentation (eg, procedure report) along with the claim to third-party payers in order to provide an adequate description of the nature and extent of the procedure
the need for the procedure
and the time, effort, and equipment necessary to provide the service
Drug Testing vs Organ or Disease-Oriented Panels
Organ or Disease-Oriented Panels
Organ or Disease-Oriented Panel codes consist of multiple tests that the physician performs to determine if there are any abnormalities with the patient
These Organ or Disease-Oriented Panel tests include both the technical component (which is the actual running of the test, HCPCS modifier TC) and the professional component (the physician is only reading and interpreting the test results, CPT modifier 26)
When reporting the panel codes, all the components listed under the code descriptor must be performed, with no substitutions
If fewer tests are performed than those listed in the panel code, the individual code number(s) for each test should be listed rather than the panel code
Even if only 1 of the components listed in the code descriptor is missing, the panel code cannot be reported
Instead, report each of the other codes separately
For example, see code 80047, Basic metabolic panel (Calcium, ionized)
Under the code descriptor it lists the components that must be included in order to report that panel code along with the code for each individual component: Calcium, ionized (82330), Carbon dioxide (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Potassium (84132), Sodium (84295), Urea Nitrogen (BUN) (84520)
If, for example, the Glucose test was not performed and all the others listed in the code descriptor were performed, then it would not be appropriate to report code 80047
Instead all of the other components would be reported individually by the codes provided in the parenthesis
These panel components are not intended to limit the performance of other tests
If a physician performs tests in addition to those specifically indicated for a particular panel, those tests should be reported separately in addition to the panel code
The presence or absence of a specific code for a panel of tests in no way limits the physician’s ability to order or perform a specific battery of tests
Whether a specific panel code exists or not affects only the method of reporting the tests performed
Some clinical laboratories may define their own panels for the ordering provider’s convenience
When a panel of tests is not described by a specific CPT panel code, the tests contained within the laboratory-defined panels are reported with the individual component CPT codes

Consider the following coding example:

Dr E performs a lipid panel on automated equipment in his office

The battery of tests he provides includes high-density lipoprotein cholesterol, total serum cholesterol, triglycerides, and quantitative glucose
Although the test for quantitative glucose is not included in the code descriptor for the lipid panel, the test is reported in addition

Dr E reports the following two codes for the panel performed:

80061

Lipid panel
This panel must include the following:
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718)
Triglycerides (84478)
82947 Glucose
quantitative, blood (except reagent strip)
On another note, if the same component is listed in more than one panel code, do not report those codes together
Said a different way, if the components of two groups of tests overlap in any respect, report the panel that incorporates the greater number of tests to fulfill the code definition and then report the remaining tests using individual test codes
For example, do not report 80047 in conjunction with 80053, as the code descriptors list some of the same components in both panel codes
All of the components listed in code 80047 are also listed in code 88053
If all of the components list in 80053 were performed, then only code 80053 would be reported
1
Can codes 80048 and 80051 be reported together? Why or why not?
Drug Testing
The CPT codes used to report drug testing are located in three sections of the Pathology and Laboratory chapter of the CPT codebook: Drug Testing (80100-80104), Therapeutic Drug Assays (80150-80299), and Chemistry (82000-84999)
Qualitative assays are tests that detect whether a particular analyte, constituent, or condition is present and reported with the drug testing codes
The term analyte is the actual drug being tested for, such as amphetamines and barbiturates
Quantitative assays are tests that give results expressing the specific numerical amount of an analyte in a specimen and are reported with the therapeutic drug assay or chemistry codes
The term assay is the determination of the amount of a particular part of a mixture or the determination of the biological or pharmacological potency of a drug
Analyte: The actual drug being tested for, such as amphetamines and barbiturates
The codes used to report qualitative drug testing distinguish between screening tests and confirmation tests
When drugs or classes of drugs are assayed by qualitative screen and followed by confirmation with a second method, the confirmation is included and is not reported separately
These tests are looking to see if traces of the drug are present in the specimen
Code 80100, Drug screen, qualitative
multiple drug classes chromatographic method, each procedure, means that this one procedure detects multiple drug classes and is counted as one procedure, regardless of the number of drugs tested
Code 80101, Drug screen, qualitative
single drug class method (eg, immunoassay, enzyme assay), each drug class, means that this method detects a single class of drugs and is to be reported as one drug class
Therapeutic Drug Assays
The material for these examinations may be from any source, such as blood, tissue, feces, or urine
Therapeutic Drug Assay examinations are quantitative, meaning the physician is looking for the number or quantity of the drug present, or how much of the drug is there
When performing nonquantitative testing, the Drug Testing codes are used
The drugs in these sections are listed in alphabetical order
Pathology Consultations
There are three different sets of codes in the Pathology and Laboratory section of the CPT codebook for reporting various types of pathology consultative services

The three different types of consultative services include the following:

Clinical pathology consultations

Consultation on referred material
and
Pathology consultation during surgery
The various pathology consultation services codes are similar to the other CPT consultation codes found in the Evaluation and Management (E/M) section in that they describe physician pathology services provided at the request of another physician of the same facility or another facility or institution
In contrast to the E/M consultation services, pathology consultations do not require a face-to-face encounter with the patient
If there is a face-to-face encounter, then the pathologist may report the appropriate E/M consultation code(s) with the appropriate modifier(s), if needed

The pathology consultation codes are reported if the following services are performed:

At the request of the attending physician of the same or another institution relevant to test result(s) requiring further medical interpretation

For consultation and report on material referred from another pathologist or facility
For consultation provided to another pathologist in a different practice site or facility
For consultation provided to another physician in the same facility or site on material from another institution (eg, review of slides before surgery or therapy at the consulting physician’s facility)
and
During surgery or other invasive procedures
Consultations (Clinical Pathology)
A clinical pathology consultation is a service that includes a written report and is rendered by the pathologist in response to a request from an attending physician regarding test result(s) that require additional medical interpretive judgment
Reporting of a test result without medical interpretive judgment is not considered a clinical pathology consultation
Pathology Consultation During Surgery
To appropriately report these codes, it is necessary to understand the definitions of tissue blocks and tissue sections
A tissue block is a portion of tissue from a specimen that is frozen or encased in a support medium such as paraffin or plastic, from which sections are prepared
A tissue section is a thin slice of tissue from that tissue block prepared for microscopic examination
When a single frozen section (ie, the first and only tissue block) from a specimen is examined, the service is coded as 88331, Pathology consultation during surgery
first tissue block, with frozen section(s), single specimen
When frozen sections from more than one tissue block from the same specimen are examined, the appropriate coding is one unit of service of code 88331 for the first tissue block and an additional unit of service with add-on code 88332, Pathology consultation during surgery
each additional tissue block with frozen section(s), for each block subsequent to the first
Code 88332 is reported only when a single specimen requires multiple frozen section tissue blocks
CPT code 88332 cannot be reported for a specimen that has not already been examined initially, as indicated by code 88331
If more than one specimen is submitted for consultation, the services for each specimen would be separately coded, as appropriate
2
If three frozen section tissue blocks from one specimen are examined, how is this reported?
Urinalysis
Codes in the Urinalysis section (81000-81099) are used to report various types of urinalysis
The note at the beginning of this section indicates that many specific quantitative analyses are not reported with codes from this section
rather, the user is directed to see the appropriate section where the specific test is described
For example, quantitative testing for urinary chloride is not in the Urinalysis section and would be reported with code 82436, Chloride
urine, from the Chemistry section
Appropriate code selection from the Urinalysis section depends on the type of test performed
In order to select the appropriate code, one must know whether the testing was automated or not and whether the testing was performed with or without microscopy
It is important to note that when urinalysis is reported, multiple tests described within a single code descriptor should not be unbundled to produce and report multiple codes
Code 81000, Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents
non-automated, with microscopy, which describes urinalysis with microscopy, should not be coded as 81005, Urinalysis
qualitative or semiquantitative, except immunoassays, for the urinalysis plus 81015, Urinalysis
microscopic only, for the microscopic examination, as this would be considered unbundling
For the Chemistry codes, if you cannot find the analyte, code by general methodology using codes 83516-83520
Molecular diagnostic codes 83890-83913 are coded by procedure rather than by analyte
Each technique used in the analyses is to be reported separately
To report Immunology codes (86000-86849):
1
Look for the analyte
and
2
Look for the general methodology if the specific analyte is not in the CPT codebook
If the general methodology code is not there, use the unlisted code (86849)
Chemistry
The material for examination may be from any source unless otherwise specified in the code descriptor
When an analyte (or drug) is measured in multiple specimens from different sources (eg, urine, blood), the analyte is reported separately for each source and for each specimen
For instance, when the analyte Catecholamines is being tested from both the urine and the blood, both sources for the specimen are reported with code 82382, Catecholamines
total urine, and code 82383, Catecholamines
blood
Likewise, when an analyte (or drug) is measured in specimens that are obtained at different times, the analyte is reported separately for each source and for each specimen
The Chemistry examinations are quantitative unless specified (eg, code 82127, Amino acids
single, qualitative, each specimen)
The Chemistry section is in alphabetical order, which is helpful in locating the correct code
With the chemistry codes, it is appropriate to report for each test done (eg, if testing for calcium and aluminum, it is appropriate to report the code for each)

The basic rule for coding these Chemistry codes is as follows:

1

Code for the analyte
and
2
Check for the source (eg, serum, urine, blood)
In the event an automated screening procedure fails, it provides no information and testing is essentially not performed
Therefore, it is not appropriate to report a laboratory test that was not performed, regardless of whether the sample was unacceptable or if the analyzer failed
Cytopathology
The Bethesda system of reporting is a format for reporting cervical-vaginal cytologic diagnoses
The Cytopathology section has specific codes used for the manual screening of conventional Pap smears that are reported by means of the non-Bethesda system of reporting, as well as specific codes used for the manual screening of conventional Pap smears that are reported by means of the Bethesda system of reporting

The Bethesda system has the following four basic elements:

1

Specimen type (conventional smear vs
liquid-based preparation vs
other)
2
Statement of specimen adequacy (an integral part of the report)
3
General categorization (aids clinicians in prioritizing cases for review or to assist laboratories in compiling statistical information)
and
4
Interpretation or result (descriptive diagnoses grouped into categories)
Note: although the general CPT guidelines state that when a code is not available for a particular procedure or service, a code similar to the actual procedure performed should not be selected in lieu of an unlisted procedure code
Instead the unlisted code should be reported
However, the one exception to this rule is for the Surgical Pathology codes, in which any unlisted specimen should be assigned the code that most closely reflects the physician work involved in securing it
Surgical Pathology
Services 88300 through 88309 include accession, examination, and reporting
The unit of service for codes 88300 through 88309 is the specimen
A specimen is defined as tissue(s) that is submitted for individual and separate attention, requiring individual examination and pathologic diagnosis
Two or more such specimens from the same patient (eg, separately identified endoscopic biopsies, skin lesions) are each appropriately assigned an individual code reflective of its proper level of service
Specimen: Tissue(s) that is submitted for individual and separate attention, requiring individual examination and pathologic diagnosis
1
No, codes 80048 and 80051 cannot be reported together, because both codes contain the same component in the code descriptors (carbon dioxide, chloride, potassium, and sodium)
2
This is reported with 1 unit of 88331 and 2 units of 88332
Code 88331 is reported for the first frozen section tissue block, and since there were two additional frozen tissue blocks examined, the add-on code 88332 would be reported twice—once for each additional tissue block

BOOK II COMPLETED

PRINCIPLES OF CPT CODING
BOOK III

CHAPTER 6
Pathology and Laboratory
This chapter reviews the Pathology and Laboratory section of the CPTR code set

Services in the Pathology and Laboratory section are provided by physicians, technologists, and other qualified laboratory (eg, medical technologists) and nonlaboratory (eg, nurses, pharmacists) health care professionals under the responsible supervision of a physician or other qualified health care professional
This chapter, in addition to discussing appropriate coding for the collection of specimens, focuses on guidelines for codes in the following subsections:
Organ or Disease-Oriented Panels
Drug Testing
Therapeutic Drug Assays
Evocative/Suppression Testing
Consultations (Clinical and Surgical Pathology)
Urinalysis
Molecular Pathology
Tier 1 Molecular Pathology Procedures
Tier 2 Molecular Pathology Procedures
Multianalyte Assays with Algorithmic Analyses
Chemistry
Hematology and Coagulation
Transfusion Medicine
Microbiology
Cytopathology
Fine Needle Aspiration
Cytogenetic Studies
Surgical Pathology
In Vivo (eg, Transcutaneous) Laboratory Procedures
Reproductive Medicine Procedures
Other Procedures
CODING TIP The use of modifier 26, Professional component, is required for CPT codes 80047-89356 when the physician is billing only for the professional component of the laboratory tests (eg, medical direction, supervision, or interpretation)
This method of reporting is appropriate when the technical and professional components are performed by different physicians or qualified health care professionals
Collection of Specimen
The 80000 series of codes is for reporting the performance of a specific laboratory test only and does not include the collection of the specimen via venipuncture, arterial puncture, or other collection method (eg, lumbar puncture)
The collection of the specimen by venipuncture or by arterial puncture is not considered an integral part of the laboratory procedure(s) performed
Codes in the 36400-36425 series are used to report venipuncture for obtaining blood specimens
The collection of specimens by venipuncture is reported with code 36415, Collection of venous blood by venipuncture
Collection of a capillary blood specimen (eg, finger, heel, or earlobe stick) is reported with code 36416
Code 36415 should not be reported in conjunction with modifier 63
When a venipuncture or a finger, heel, or earlobe stick is performed for collection of specimens, this code is reported in addition to the appropriate code(s) from the 80000 series for the laboratory procedure
CODING TIP Code 99195, found in the Medicine section of the CPT code set, describes a therapeutic phlebotomy
Therapeutic phlebotomy is often used in the treatment of polycythemia vera to reduce the hematocrit and red blood cell (RBC) mass and in the treatment of other diseases
Although obtaining a blood sample is frequently referred to as phlebotomy, this is not the appropriate code for reporting the acquisition of blood specimens for laboratory studies
It is appropriate to report code 36591 or 36592 for a blood specimen collection performed for a laboratory service (eg, 85025 [CBC])
The services described by codes 36591 and 36592 include irrigation of the venous access device
Therefore, it would not be appropriate to additionally report code 96523
Codes 36591 and 36592 are not reported in conjunction with any service except a laboratory service
CPT code 36600, Arterial puncture, withdrawal of blood for diagnosis, is used to report the puncture of an artery for withdrawal of blood for diagnosis
If this procedure is performed, it would be appropriate to report code 36600 for the collection of the specimen
This code is reported in addition to the appropriate code(s) from the 80000 series for the laboratory procedure
Organ or Disease-Oriented Panels
Organ or disease-oriented panels are reported with the codes from the 80047-80076 series
These panels were developed for coding purposes and should not be interpreted as clinical standards for testing
Each panel includes a defined list of tests
The tests listed with each panel identify the defined components of the panel
To report a code for a panel, all of the tests listed in the panel definition must be performed, with no substitutions
If fewer tests are performed than listed in the panel code, the individual code numbers for each test done should be listed rather than the panel code
The panel components are not intended to limit the performance of other tests
If tests are performed in addition to the tests listed for a panel, the additional tests would be reported separately in addition to the panel code
Two or more panel codes that include any of the same constituent tests performed from the same patient collection should not be reported
If a group of tests overlaps 2 or more panels, the panel code that incorporates the greater number of tests to fulfill the code definition is reported and the remaining tests are reported using individual test codes (eg, do not report code 80047 in conjunction with code 80053)
The presence or absence of a specific code for a panel of tests in no way limits the ability of a physician or other qualified health care professional to order or perform a specific battery of tests
Whether a specific panel code exists affects only the method of reporting the tests performed
Clinical laboratories may define their own panels for the convenience of the ordering providers
When not described by a specific CPT panel, the tests listed in the laboratory-defined panels are billed by means of the individual component CPT codes
Consider the following coding examples:
EXAMPLE 1
Dr Alder performs a lipid panel on automated equipment in his office
The battery of tests he provides includes high-density lipoprotein cholesterol, total serum cholesterol, triglycerides, and quantitative glucose
Dr Alder reports the following codes for the panel performed:
80061
Lipid panel
This panel must include the following:
Cholesterol, serum, total (82465)
Lipoprotein, direct measurement, high-density cholesterol (HDL cholesterol) (83718)
Triglycerides (84478)82947 Glucose
quantitative, blood (except reagent strip)
EXAMPLE 2
Dr Bender performs a metabolic panel on automated equipment in her office
The tests she includes in her battery of tests are serum carbon dioxide, chloride, creatinine, glucose, potassium, sodium, and blood urea nitrogen (BUN)

The following 3 code listings are found in the CPT code set for reporting metabolic panels:

80047

Basic metabolic panel (Calcium, ionized)
This panel must include the following:
Calcium, ionized (82330)
Carbon dioxide (82374)
Chloride (82435)
Creatinine (82565)
Glucose (82947)
Potassium (84132)
Sodium (84295)
Urea Nitrogen (BUN) (84520)80048 Basic metabolic panel (Calcium, total)
This panel must include the following:
Calcium, total (82310)
Carbon dioxide (82374)
Chloride (82435)
Creatinine (82565)
Glucose (82947)
Potassium (84132)
Sodium (84295)
Urea nitrogen (BUN) (84520)80053 Comprehensive metabolic panel
This panel must include the following:
Albumin (82040)
Bilirubin, total (82247)
Calcium, total (82310)
Carbon dioxide (bicarbonate) (82374)
Chloride (82435)
Creatinine (82565)
Glucose (82947)
Phosphatase, alkaline (84075)
Potassium (84132)
Protein, total (84155)
Sodium (84295)
Transferase, alanine amino (ALT) (SGPT) (84460)
Transferase, aspartate amino (AST) (SGOT) (84450)
Urea nitrogen (BUN) (84520)
Panel codes 80047, 80048, and 80053 do not accurately describe Dr Bender’s metabolic panel

It would not be appropriate for Dr Bender to report codes 80047 or 80048 because she does not include total calcium (82310) or ionized calcium (82330) as a component of her panel
It would also not be appropriate for Dr Bender to report code 80053 because her panel does not include all of the test components listed in this code
The appropriate way for Dr Bender to report her metabolic panel is to report the code for the electrolyte panel and separately report the creatinine, glucose, and BUN
The following codes would be reported:
Test
CPT Code
Electrolyte panel80051
Creatinine82565
Glucose

82947
BUN

84520
Drug Testing
The CPT codes used to report drug testing are located in 3 subsections of the Pathology and Laboratory section of the CPT code set: Drug Testing (80100-80104), Therapeutic Drug Assays (80150-80299), and Chemistry (82000-84999)

Qualitative assays (tests that detect whether a particular analyte, constituent, or condition is present) are reported with the drug testing codes
quantitative assays (tests that give results expressing the specific numeric amount of an analyte in a specimen) are reported with the therapeutic drug assay or chemistry codes (Table 6-1)

TABLE 6-1 Table of Drugs and the Appropriate Qualitative Screening, Confirmatory, and Quantitative Codes

a Code 80100 is used for each combination of mobile phase with stationary phase

b Code 80101 is used for each single drug class tested and reported
c Code 80102 is used for each combination of mobile phase with stationary phase used for drug confirmation
d Code 82055 is used for “Alcohol (ethanol)
any specimen except breath” and code 82075 for “Alcohol (ethanol)
breath

e Code 80184 is used for “Phenobarbital,” 80188 for “Primidone,” and 82205 for “Barbiturates, not elsewhere specified

f If there is no appropriate quantitative code for the drug listed, the appropriate chromatographic code (eg, 82491) or unlisted drug quantitation code (80299) for other methods is used
g Code 80152 is used for “Amitriptyline,” 80160 for “Desipramine,” 80166 for “Doxepin,” 80174 for “Imipramine,” and 80182 for “Nortriptyline

The codes used to report qualitative drug testing distinguish between screening tests (80100, 80104, and 80101) and confirmatory testing (80102)
The screening tests are further distinguished by the methods used to analyze multiple drug classes (80100, 80104) and those that test for a single drug class (80101)
The codes are intended to distinguish among analytic methods rather than the platform or instrumentation on which any particular method is run
For example, immunoassays, which are used to identify single classes of drugs, should be reported with code 80101 (when used in drug screening), whether the test is performed with a random access analyzer, a single-analyte test kit, or a multiple analyte test kit
Chromatography, which can identify multiple drug classes, is reported with code 80100 (when used in drug screening)
Code 80104 is reported to describe a nonchromatographic method wherein, owing to the test kit design, multiple drug classes are screened and identified in a single test procedure
Kits are commercially available for 12 or more analytes
These test kits are often called “multiplexed” because of the ability to qualitatively assay multiple drugs simultaneously
Code 80104 is a resequenced code
therefore, it does not appear in numeric order in the Drug Testing subsection of the CPT code set
For code 80100, each combination of stationary and mobile phase is counted as 1 procedure
For example, if screening for 3 drugs by chromatography requires 1 stationary phase with 3 mobile phases, code 80100 is reported 3 times
However, if multiple drugs can be detected with a single analysis (eg, 1 stationary phase with 1 mobile phase), code 80100 is reported only once
EXAMPLE 1
A patient is admitted to the emergency department in a coma, and a drug screen is ordered without identifying a specific drug class to be tested
The laboratory performs a multiple drug class screen by means of thin-layer chromatography with a single mobile and stationary phase
For the laboratory procedure, CPT code 80100 would be reported because this code is used for qualitative drug screening by chromatographic methods
One unit would be coded for the single stationary and mobile phase combination
For code 80101, each single drug class method tested and reported is counted as 1 drug class
For example, if a specimen is divided into aliquots for 5 wells and separate class-specific immunoassays are run on each of the 5 wells and reported separately, code 80101 is reported 5 times
Similarly, if a sample is run on a rapid assay kit composed of 5 class-specific immunoassays in a single kit and the 5 classes are reported separately, code 80101 should be reported 5 times
EXAMPLE 2
A patient is admitted to the emergency department in a coma
family members describe a history of anxiety and depression that has been treated with prescription medications
A drug screen for alcohol, barbiturates, benzodiazepines, phenothiazines, and tricyclic antidepressants is ordered
The laboratory performs single drug class screening for each analyte by means of immunoassay methods on a random access analyzer
Code 80101 would be reported 5 times because this code is used to report immunoassay and enzyme assay, single drug class methods
Five units are reported because each single drug class is reported separately
EXAMPLE 3
A patient is admitted to the emergency department in a coma with a known history of illicit drug use
A drug screen for amphetamines, barbiturates, benzodiazepines, cocaine and metabolites, opiates, phencyclidine, and tetrahydrocannabinoids is ordered
The laboratory performs single drug class screening for each analyte by means of a multiple-analyte rapid test immunoassay kit
Code 80101 would be reported 7 times because immunoassay single drug class methods are reported with this code regardless of platform (random access analyzer or multiple-analyte test kit)
Seven units are reported because each single drug class is reported separately
For each procedure requiring confirmation, code 80102 is used
As with the screening code (80100) for chromatography, and screening code 80104 for methods other than chromatography, each combination of stationary and mobile phase is counted as 1 procedure
For example, if confirmation of 3 drugs by chromatography requires 1 stationary phase with 3 mobile phases, code 80102 is reported 3 times
However, if multiple drugs can be confirmed with a single analysis (eg, 1 stationary phase with 1 mobile phase), code 80102 is reported only once
EXAMPLE 4
A patient is admitted to the emergency department in a coma with a known history of illicit drug use
A drug screen without identifying a specific drug class to be tested is ordered
The laboratory performs a multiple drug class screen and reports positive results, consistent with opiates
A confirmatory test is ordered, which the laboratory runs to confirm opiates by means of high-performance liquid chromatography (not quantitative)
To code the multiple drug class screen, chromatographic method, code 80100 is used (1 unit would be coded)
To code the confirmatory test, code 80102 is reported because this code is used to report confirmatory testing without quantification
One unit would be coded for the single stationary-mobile phase
Quantitative assays should be reported with the appropriate code in the Therapeutic Drug subsection (80150-80299) or Chemistry subsection (82000-84999)
Quantitative chromatography for analytes not specified in those sections may be coded with the appropriate chromatographic code (eg, 82491, 82492)
For quantitative immunoassays or other nonchromatographic methods for analytes not specified in those sections, code 80299 is used
Therapeutic Drug Assays
Therapeutic drug assays are reported with the codes in the 80150-80299 series, unless a chromatographic method is used
The material for examination may be from any source
The codes in this series represent quantitative examinations (ie, the results will express the specific quantity of the drug present in the specimen as a numeric result)
Quantitative chromatographic methods used for analytes not specified in the Therapeutic Drug Assay subsection may be coded with the appropriate chromatographic code (eg, 82491, 82492)
For quantitative immunoassays or other nonchromatographic methods for analytes not specified, whether by trade or generic name, in those sections, code 80299 is used
Nonquantitative or qualitative drug testing is reported with the codes in the 80100-80104 series
Qualitative tests detect only whether a particular analyte, constituent, or condition is present without expressing results as a numeric value
When code 80299 is reported, it may be necessary to report the specific therapeutic drug assay performed on the submitted claim
Before reporting code 80299, coders should also look to the Chemistry section (82000-84999) for the specific analyte
To illustrate, opiate testing is not listed among the therapeutic drug assay codes in the 80150-80299 series
Therefore, the instruction to use code 80299 is not applicable to quantitative opiate testing
Another set of laboratory medicine codes that could be considered appropriate for opiate testing is the set of quantitative chromatography codes (82491, 82492, 82542, 82543, and 82544), but these codes are reported for analytes not elsewhere specified
But by CPT convention, in the chemistry section, method codes are generally not appropriate when a specific analyte code is available
Hence, this series should not be used for opiate testing
Code 83925 does not specify any particular type of opiate or opioid drug, nor does it differentiate the source (eg, urine or serum)
The descriptor reflects its use for examining opiate metabolites because the analyte may also exist as a metabolite of another opiate-based medication
Therefore, multiple testing may be required with quantification of the opiate and then further quantifying of the presence of a metabolite or metabolites
The unit of service designation for this service is each procedure as opposed to each analyte or other unit measure
Because each procedure is reported separately using the same CPT code, code 83925 may be reported with the modifier 59 appended
Certain payers may require the use of modifier 59 when the same CPT code is used
alternatively, the payer may require completion of the units box on the claim form
CODING TIP The specimen (eg, urine or serum) may be from any source for the therapeutic drug assays reported with codes 80150-80299
The CPT code set lists the generic (nonproprietary) names of drugs whenever possible
If the specific drug for which the therapeutic drug assay is performed, whether by trade or generic name, is not found in the 80150-80202 series, code 80299, Quantitation of drug, not elsewhere specified, is appropriately reported
Table 6-2 is provided to assist in cross-referencing commonly used trade names of drugs with their generic names
The trade names in this table are limited to those marketed in the United States
The table is not all-inclusive, and not every trade name in current use is listed for each drug
The inclusion or exclusion of a drug in this table does not indicate approval or disapproval of its use in any category, nor is any efficacy or safety implied
TABLE 6-2 Crosswalk Table of Generic and Brand Name Drugs
Generic Name
Brand Name
Amikacin Amikin
Amitriptyline Elavil, Endep
Carbamazepine Tegretol
Desipramine Norpramin
Digoxin Lanoxin
Doxepin Adapin, Sinequan
Gentamicin
Garamycin
Imipramine Tofranil
Lidocaine Xylocaine
Lithium Eskalith, Lithobid
Phenobarbital Donnatal
Phenytoin Dilantin
Primidone Mysoline
Procainamide Pronestyl
Quinidine Quinaglute, Quinidex
Theophylline Respbid, Theo-Dur, Theo-24
Tobramycin Nebcin
Evocative or Suppression Testing
Evocative or suppression testing is reported with the codes in the 80400-80440 series for laboratory procedures only
In the code descriptors in which reference is made to a particular analyte, eg, cortisol
total (82533 x 2), the “x 2” refers to the number of times the test for that particular analyte is performed
Some of the code descriptors indicate that the test is performed on pooled blood samples
When an analyte varies in the blood level from moment to moment, a more reliable baseline value may be obtained by obtaining several specimens several minutes apart, pooling equal portions of each, and obtaining 1 result (a pooled result)
The notes that appear at the beginning of this series of codes indicate how to code the additional services that may be a part of the complex series of events or actions associated with the test
Evocative and suppression test protocols involve the administration of evocative or suppressive agents and the baseline and subsequent measurement of their effects on chemical constituents
Codes 80400-80440 are used to report the laboratory component of the overall testing protocol
The laboratory panel itself may describe only a small portion of the protocol in some cases
The administration of the evocative or suppressive agents is reported separately with the codes in the 96360, 96361, and 96365-96376 series describing hydration, therapeutic, prophylactic, and diagnostic injections and infusions
The supplies and drugs are separately reported with CPT code 99070 or the appropriate Healthcare Common Procedure Coding System (HCPCS) Level II codes for supplies and drugs
(Refer to Chapter 7 for further discussion of codes 96360, 96361, and 96365-96376
)
To report attendance and monitoring during testing, the appropriate evaluation and management (E/M) code is used, including the prolonged services codes, if required
Consultations (Clinical and Surgical Pathology)
There are 3 sets of codes in the Pathology and Laboratory section of the CPT code set for reporting various types of consultative services
The 3 types of consultative services include the following:
Clinical pathology consultations: 80500-80502
Consultation on referred material: 88321-88325
Pathology consultation during surgery: 88329-88334
The various pathology consultation services codes are similar to the other CPT consultation codes found in the E/M section in that they describe pathology services provided at the request of another physician or other qualified health care professional from the same or another facility or institution
In contrast with the E/M consultation services, pathology consultations do not require a face-to-face encounter with the patient
If there is a face-to-face encounter, pathologists should use the appropriate E/M consultation code(s) with the appropriate modifier(s), if any
The pathology consultation codes are reported if the following services are performed:
Further medical interpretation relevant to test result(s) at the request of the attending physician from the same or another institution
Consultation and report on material referred from another pathologist, qualified health care professional, or facility
Consultation provided to another pathologist or qualified health care professional in a different practice site or facility
Consultation provided to another physician or other qualified health care provider in the same facility or site on material from another institution (eg, review of slides before surgery or therapy at the consulting facility)
Consultation during surgery or other invasive procedures
The following section examines the 3 sets of codes available and the guidelines for reporting these pathology consultative services
CODING TIP Codes 80500 and 80502 are differentiated according to whether a review of the patient’s history and medical records is performed as part of the consultative service
Code 80500 includes review and interpretation of test results only
Code 80502 is a more extensive consultative service in which the physician must review additional patient information to provide medical interpretive judgment
Clinical Pathology Consultations
CPT codes 80500 and 80502 are used to report a clinical pathology consultation
The code descriptors appear in the CPT code set as follows:
80500
Clinical pathology consultation
limited, without review of patient’s history and medical records
80502
comprehensive, for a complex diagnostic problem, with review of patient’s history and medical records
A clinical pathology consultation is a service including a written report by the pathologist or other qualified health care professional in response to a request from an attending physician in relation to test results requiring additional medical interpretive judgment
Code 80500 may also be used to report clinical correlation of gynecologic cytology (eg, Papanicolaou [Pap] test) and follow-up histologic findings, as mandated by the Clinical Laboratory Improvement Amendments of 1988, when the clinical pathology consultations include a written report
Consultation on Referred Material
CPT codes 88321, 88323, and 88325 are used to report consultations and reports on material referred from another source (eg, from another pathologist, health care professional, or facility)
The code descriptors appear in the CPT code set as follows:
88321
Consultation and report on referred slides prepared elsewhere
88323 Consultation and report on referred material requiring preparation of slides
88325 Consultation, comprehensive, with review of records and specimens, with report on referred material
These codes are appropriate for use in reporting consultations provided to another physician or other qualified health care professional in a different practice site or facility or in the same facility or site on material referred from an outside source (eg, review of slides from another institution before surgery or therapy at the consulting facility)
As indicated in the code descriptors, code 88321 is used to report a consultation on referred material that does not require the preparation of routinely stained slides
Code 88323 describes the provision of a consultation and report on referred material when the consultant prepares the slides for routine histologic staining
When special stains or immunohistochemical stains are done in addition to the routine stain, they should be coded separately
Code 88325 is reported for a more comprehensive consultative service on referred material that involves review of patient records and specimens
Pathology Consultation During Surgery
Codes 88329 and 88331-88334 are available for reporting a pathology consultation during surgery or similar invasive procedure (eg, computed tomography-guided biopsy)
The code descriptors appear in the CPT code set as follows:
88329
Pathology consultation during surgery
88331
first tissue block, with frozen section(s), single specimen
+88332 each additional tissue block with frozen section(s)
88333 cytologic examination (eg, touch prep, squash prep), initial site
+88334 cytologic examination (eg, touch prep, squash prep), each additional site
To appropriately report these codes, it is necessary to understand the definitions of tissue blocks and sections
A block is a portion of tissue from a specimen that is frozen or encased in a support medium such as paraffin or plastic, from which sections are prepared
A section is a thin slice of tissue from a block prepared for microscopic examination
When the pathology consultation during surgery does not involve microscopic examination of tissue, the service is coded as 88329, Pathology consultation during surgery
When a single frozen section (ie, the first and only tissue block) from a specimen is examined, the service is coded as 88331, Pathology consultation during surgery
first tissue block, with frozen section(s), single specimen
When frozen sections from more than 1 block from the same specimen are examined, the appropriate coding is one unit of service of code 88331 for the first tissue block and an additional unit of service of code 88332, Pathology consultation during surgery
each additional tissue block with frozen section(s), for each block after the first
Code 88332 is reported only when a single specimen requires multiple frozen section tissue blocks
Code 88332 is an add-on code and is reported only in conjunction with code 88331
Therefore, CPT code 88332 may not be reported for a specimen that has not already been examined initially, as indicated by code 88331
If more than 1 specimen is submitted for consultation, the services for each specimen would be separately coded, as appropriate
Two intraoperative cytologic evaluation codes are also available: 88333, Pathology consultation during surgery
cytologic examination (eg, touch prep, squash prep), initial site, and 88334, Pathology consultation during surgery
cytologic examination (eg, touch prep, squash prep), each additional site
Code 88334 is designated as an add-on code
Therefore, code 88334 is reported in conjunction with codes 88331 and 88333, which precludes its use as a stand-alone code
These codes are structured similarly to the frozen section codes 88331 and 88332
Codes 88333 and 88334 are reported for intraoperative or intraprocedural cytologic examination (via touch or squash preparation) and consultation to provide immediate diagnoses during an intraoperative consultation without the use of frozen section
The important differentiation between the frozen section codes and the cytology codes is that, whereas codes 88331 and 88332 are billed per block, codes 88333 and 88334 are billed per specimen site
An important list of parenthetical comments follows these codes defining the appropriate use of codes 88333 and 88334
For example, when intraoperative cytology is performed in conjunction with frozen section analysis, the first frozen section per specimen is coded with 88331, and all cytologic preparations performed on the same specimen are reported with 1 unit of code 88334 per site
Also, for percutaneous needle biopsy requiring intraprocedural cytologic examination, code 88333 is used
However, if the frozen section and touch preparation are performed simultaneously, complementarily aiding in the same specific diagnosis, only the frozen section code should be reported (eg, a squash preparation and a frozen section analyzed together on the same brain biopsy specimen being assessed for glioma)
CODING TIP Intraprocedural cytologic evaluation of a fine-needle aspirate is reported with code 88172
It is not appropriate to report codes 88333 and 88334 for the same specimen
The following are examples of appropriate coding for pathology consultations during surgery
EXAMPLE 1
A basal cell carcinoma is removed from a patient’s forehead and submitted as a specimen for frozen section
Frozen section on 1 area is performed
The margin on one side is not adequate, so the surgeon resects more tissue from the same wound and submits this specimen for frozen section
One frozen section is performed on this specimen
For the pathology services provided, CPT code 88331 would be reported for the first specimen submitted
The margin on one side was not adequate, and the surgeon resected more tissue from the same wound and submitted it for frozen section
This second specimen submitted is reported as a “new” specimen and is reported as a separate frozen section examination with code 88331
Therefore, to completely report the intraoperative services described, code 88331 would be reported twice
The pathologist routinely also processes the tissue remaining after a frozen section
The permanent sections also require analysis, and, in the case described, 2 units of code 88305 (for the 2 tissue specimens) would be reported
EXAMPLE 2
During a radical prostatectomy, obturator lymph nodes from the right and left sides are submitted as separate specimens for immediate diagnosis with respect to involvement with metastatic disease
The pathologist examines each of these specimens and selects portions of lymph nodes resulting in 2 blocks on the right side and 3 blocks on the left side for frozen sections, which are examined microscopically
In this example, for the specimen from the right side, the pathology services provided would be reported with codes 88331 and 88332 (2 blocks on the right side—code 88331 for the first block and code 88332 for the second block)
For the separate specimen from the left side, the pathology services provided would be reported with code 88331 and code 88332 twice (3 blocks on the left side—code 88331 for the first block and code 88332 twice, once for the second block and once for the third block)
Therefore, to code for the frozen section analyses in this example, code 88331 would be reported 2 times and code 88332 would be reported 3 times
When a pathology consultation is performed that includes examination of the patient, the appropriate level of E/M code should be reported, provided the guidelines for reporting have been met and documented in the medical record
Urinalysis
Codes in the 81000-81099 series are used to report various types of urinalysis
The note at the beginning of this subsection indicates that many specific quantitative analyses are not reported with codes from this subsection
rather, the user is directed to the appropriate section where the specific test is described
For example, quantitative testing for urinary chloride would be reported with code 82436, Chloride
urine, from the Chemistry subsection
The codes available in this subsection include the following:
Codes 81000-81003 are used to report urinalysis by dipstick or tablet reagent
The following constituents are included when urinalysis by dipstick or tablet reagent is reported:
Bilirubin
Glucose
Hemoglobin
Ketones
Leukocytes
Nitrite
pH
Protein
Specific gravity
Urobilinogen
As indicated in the code descriptor, these codes are applicable when testing for any number of these constituents
Appropriate code selection from the 81000-81003 series depends on the type of test performed
To select the appropriate code, one must know whether the testing was automated and whether the testing was performed with or without microscopy
When urinalysis is reported, multiple tests described in a single code should not be unbundled to produce multiple codes
For example, code 81000, which describes urinalysis with microscopy, should not be coded as 81005 for the urinalysis plus 81015 for the microscopic examination
Code 81005 is used to report qualitative or semiquantitative urinalysis, except for immunoassays
The parenthetical note following code 81005 directs users to code 83518 for reporting a qualitative or semiquantitative immunoassay
A urine pregnancy test performed by visual color comparison methods is reported with code 81025
A visual color comparison involves a pad or stick that changes color depending on the test results and is compared with a color chart that indicates positive or negative for pregnancy
Code 81050 is reported for volume measurement for timed collection
A timed collection involves collection of all urine during a specific period, such as 12 or 24 hours
As indicated in the code descriptor, this code is reported for each volume measurement
This series of codes includes an unlisted urinalysis procedure (81099)
This code is appropriately reported when a urinalysis is performed that is not more specifically identified with a code in the 81000-81050 series or by a specific code in another section
(Refer to Chapter 1 for further discussion of unlisted codes
)
Molecular Pathology
Molecular pathology procedures are medical laboratory procedures involving the analysis of nucleic acids to detect variants in genes that may be indicative of germline (eg, constitutional disorders) or somatic (eg, neoplastic) conditions or to test for histocompatibility antigens (eg, human leukocyte antigen [HLA])
Most molecular tests use a number of techniques (eg, extraction, amplification)
These procedures are grouped in a 2-tier system that captures the majority of the current molecular pathology procedures
The molecular pathology codes include all analytic services performed in the test (eg, cell analysis, nucleic acid stabilization, extraction, digestion, amplification, and detection)
Any procedures required before cell lysis (eg, microdissection, codes 88380-88381) should be reported separately
The CPT coding guidelines may differ from third-party payer guidelines
Eligibility for payment and coverage policy are determined by each individual insurer or third-party payer
It is important to be aware of the policies applicable to the jurisdiction in which you practice
CODING TIP When a Tier 1 or Tier 2 code does not exist, the unlisted molecular pathology code 81479 should be reported
Tier 1 Molecular Pathology Procedures
Tier 1 codes represent the most commonly performed molecular pathology procedures and are reported using a unique and analyte-specific Tier 1 code
Tier 1 contains more than 90 codes in the 81200-81383 series and describes specific gene and genomic procedures
The CPT code set includes detailed guidelines and parenthetical notes throughout the Molecular Pathology section for appropriate reporting of these codes
EXAMPLE 1
A patient is screened for common variants at a cystic fibrosis screening examination
Code 81222 is reported if the laboratory is evaluating a specimen for duplication/deletion variants
Code 81223 is reported if full gene sequencing is performed
Other common variant services should be reported with code 81220
If the laboratory is testing for other variants in addition to those within the American College of Medical Genetics/American College of Obstetricians and Gynecologists guidelines, they are not separately reported
EXAMPLE 2
Intermediate resolution in the HLA system testing is performed
Low and intermediate resolutions are considered low resolution for code assignment
Therefore, the low resolution code series (81370-81377) is used
EXAMPLE 3
Methylation status is determined by a method other than Southern blot
Although Southern blot analysis is the most common method currently used to characterize expanded alleles for methylation, code 81244, FMR1 (fragile X mental retardation 1) (eg, fragile X mental retardation) gene analysis
characterization of alleles (eg, expanded size and methylation status), does not specify method
If a laboratory is characterizing alleles for FMR1 using other methods, this code may also be used
CODING TIP Use the traditional HLA codes 86812-86817 only for serologic testing
When using molecular pathology techniques, use codes 81370-81383
Tier 2 Molecular Pathology Procedures
Tier 2 codes represent categories of molecular pathology services grouped based on the complexity of the services and relative resources required to perform the tests
These procedures are commonly performed, but at a lower volume than Tier 1 procedures
Tier 2 include 9 codes in the 81400-81408 series
These codes are used to report molecular pathology procedures that are not specifically described in the Tier 1 codes
The Tier 2 codes are arranged by level of technical resources and interpretive professional work required
Tier 2 codes are not to be self-assigned, which means that a Tier 2 code cannot be used for an analysis unless it is listed under that code in the CPT code set
If a procedure is not listed, the unlisted molecular pathology code, 81479, should be reported when the service is not represented by a Tier 1 or Tier 2 code
There are detailed guidelines and parenthetical notes added throughout the Molecular Pathology section to provide additional instructions for the appropriate reporting of these codes
For example, the guidelines indicate that the molecular pathology Tier 1 and Tier 2 codes should not be used for in situ hybridization analyses (eg, fluorescence in situ hybridization, often called FISH)
Code selection is typically based on the specific gene being analyzed
Genes are italicized in the code descriptors
When the gene name is represented by an abbreviation, the abbreviation is listed first followed by the full gene name italicized in parentheses (eg, F5 [coagulation factor V]
Proteins or diseases associated with the genes are listed as examples in the code descriptors
EXAMPLE 1
Array-based comparative genomic hybridization was performed for oncologic indications
Tier 2 Molecular Pathology procedure, Level 7 (code 81406) is reported because this Tier 2, Level 7 code includes the specific analysis stated in the code descriptor:
81406
Molecular pathology procedure, Level 7 (eg, analysis of 11-25 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 26-50 exons, cytogenomic array analysis for neoplasia)
Cytogenomic microarray analysis, neoplasia (eg, interrogation of copy number and loss of heterozygosity via single nucleotide polymorphism-based comparative genomic hybridization microarray analysis) is one of the procedures specified under code 81406
EXAMPLE 2
A laboratory tests for JAK2 sequencing on exon 12 and exon 13
Code 81403 is used to report JAK2 testing and indicates “exon 12 sequence and exon 13 sequence, if performed
” This phrase indicates that 1 unit of code 81403 is reported when exon 12 alone or exons 12 and 13 are sequenced
81403
Molecular pathology procedure, Level 4 (eg, analysis of single exon by DNA sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons)
JAK2 (Janus kinase 2) (eg, myeloproliferative disorder), exon 12 sequence and exon 13 sequence, if performed is one of the procedures specified under code 81403
Multianalyte Assays with Algorithmic Analyses
CPT codes are available to report Multianalyte Assays with Algorithmic Analyses (MAAAs) procedures
These procedures utilize multiple results derived from assays of various types, including molecular pathology assays, fluorescent in situ hybridization assays and nonnucleic acid-based assays (eg, proteins, polypeptides, lipids, carbohydrates)
Algorithmic analysis using the results of these assays as well as other patient information (if used) is then performed, and reported typically as a numeric score(s) or as a probability
MAAAs are typically unique to a single clinical laboratory or manufacturer
The results of individual component procedure(s) that are inputs to the MAAAs may be provided on the associated laboratory report, however these assays are not reported separately using additional codes
The format for the code descriptors of MAAAs may include:
Disease type (eg, oncology, autoimmune, tissue rejection)
Material(s) analyzed (eg, DNA, RNA, protein, antibody)
Number of markers (eg, number of genes, number of proteins)
Methodology(ies) (eg, microarray, real-time [RT]-PCR, in situ hybridization [ISH], enzyme linked immunosorbent assays [ELISA])
Number of functional domains (if indicated)
Specimen type (eg, blood, fresh tissue, formalin-fixed paraffin embedded)
Algorithm result type (eg, prognostic, diagnostic)
Report (eg, probability index, risk score)
All MAAAs codes, including those that do not have a Category I code, are located in Appendix O of the CPT codebook along with the procedure’s proprietary name
MAAAs that do not have a Category I code are identified in Appendix O by a four-digit number followed by the letter “M
” Category I MAAA codes are also included in Appendix O
When a specific MAAA procedure is not listed in Appendix O, the procedure must be reported using the Category I MAAA unlisted code (81599)
These codes encompass all analytical services required (eg, cell lysis, nucleic acid stabilization, extraction, digestion, amplification, hybridization, and detection) in addition to the algorithmic analysis itself
Procedures that are required prior to cell lysis (eg, microdissection, codes 88380 and 88381) should be reported separately

EXAMPLE: Appendix O—Multianalyte Assays with Algorithmic Analyses

Chemistry
Codes in this subsection (82000-84999) are primarily arranged alphabetically

The paragraphs that follow highlight some of the guidelines that appear at the beginning of the Chemistry subsection
The material for chemical analysis may be from any source
Exceptions to this guideline are evident when a code descriptor specifically lists the source of the specimen
When an analyte is measured in multiple specimens from different sources or in specimens obtained at different times, the analyte is reported separately for each source and for each specimen
A few examples include code 82480, Cholinesterase
serum, in which the specimen is specifically identified as serum, and code 82436, Chloride
urine, which specifies the specimen as urine
The listings in the Chemistry subsection represent quantitative examinations unless otherwise specified in the code descriptor
For multiple specimens or different sources, modifier 59 is used
For repeated laboratory tests performed on the same day, modifier 91 is used
Mathematical calculations, that is, clinical information derived from the results of laboratory data that are mathematically calculated (eg, free thyroxine index, or T7), are considered part of the test procedure and not a separately reportable service
When searching for the appropriate code(s) for a laboratory test, one should look first for a code that describes the specific analyte (substance analyzed)
If no analyte-specific code is found, one should search for a code that describes the method used in the testing procedure
“Unlisted procedure” codes ending with 99 should be used only when the analyte or method code is not listed
For example, in coding for prostate-specific antigen (PSA) testing, codes 84152-84154 specifically describe this test
these codes are analyte-specific
CPT code 86316, Immunoassay for tumor antigen, quantitative (eg, CA 50, 72-4, 549), each, also describes tumor antigen testing but cannot be reported in this situation because a specific code (the code for PSA) exists
Code 86316 describes tumor antigen testing by method (ie, immunoassay)
This code is used to report tumor antigen testing when an analyte-specific listing does not exist in the CPT code set
Although the complexed PSA result can be used much like free PSA, it should not be coded as such
The current code to report complexed PSA is code 84152
Codes in the series 84155-84157 and 84160 for measurement of total protein are intended to distinguish by specimen type
Protein electrophoresis methods are reported with codes in the 84165 and 84166 series
EXAMPLE
Dr Simpson’s patient has dry eye disease
Dr Simpson submits a sample to the pathology department for a tear osmolarity evaluation
Code 83861 is reported for the analysis of tears in conjunction with other methods of clinical evaluation of dry eye disease
For tear osmolarity of both eyes, code 83861 should be reported twice
Hematology and Coagulation
Codes in the 85002-85999 series are used to report various hematology and coagulation procedures
Blood counts and clotting factor testing are some of the procedures described in this subsection
The parenthetical note appearing at the beginning of this subsection indicates that blood banking procedures are not reported with codes in this subsection
Rather, codes in the Transfusion Medicine subsection of the CPT code set are used to report blood banking procedures
The hematology series of codes (85002-85049) includes variations of specific components and the specific methods used to obtain measurements of those components
Typically, the following components are included in a complete blood cell count (CBC):
RBC count
White blood cell (WBC) count
Hemoglobin
Hematocrit
Platelet count
RBC indices—the calculation for determining the average size, hemoglobin content, and concentration of RBCs, including the following:
Mean cell volume
Mean cell hemoglobin
Mean cell hemoglobin concentrate
Differential WBC count
CODING TIP Codes 85611 and 85732 are used to report circulating anticoagulant screen(s) (mixing studies)
Codes 85007-85009 are used to report current manual microscopic review of peripheral blood
Code 85007 describes microscopic examination of a blood smear with a manual differential leukocyte (WBC) count
Code 85008 describes a microscopic blood smear examination without a manual differential WBC count
To report an automated CBC (85027) with a manual differential WBC count (85007 or 85009) or blood smear review (85008), code 85027 should be reported with code 85007, 85008, or 85009, as appropriate
If an automated CBC and an automated differential WBC count are performed, code 85025 should be reported
Code 85032 describes each manual erythrocyte, leukocyte, or platelet count and is intended to allow for reporting of individual parts of the CBC when performed manually
When a manual CBC (RBC, WBC, hemoglobin, hematocrit, differential, and indices) is performed, codes 85014 and 85018 should be reported one time, code 85032 two times, and code 85007 or 85009 one time, as appropriate
Code 85041 describes an automated RBC count
This code should not be reported in conjunction with code 85025 or 85027 because these codes already include an automated RBC count
It should be used to report automated RBC counts only
Code 85045 describes an automated reticulocyte count
Code 85048 is used to report an automated WBC count
CODING TIP Codes 85384 and 85385 are reported for testing for clotting factor I (fibrinogen)
Code 85396 describes laboratory technology for coagulation and fibrinolysis assessment
This test is more comprehensive than the individual tests for prothrombin time (PT [85610]), partial thromboplastin time (PTT [85730, 85732]), fibrinogen (85384), phospholipid neutralization
platelet (85597), hexagonal neutralization (85598), and D-dimer (85378-85380)
Comprehensive coagulation and fibrinolysis assessment assists in determining the cause of abnormalities in the plasma components (PT, PTT, fibrinogen, platelets, D-dimer) that comprise the clotting process and how the abnormalities affect clot stability
For reporting purposes, there are 2 types of neutralization procedures designed to detect the presence of antiphospholipid antibodies: (1) platelet neutralization (85597) and (2) hexagonal phospholipid neutralization (85598)
Having specific codes for these procedures will better differentiate hexagonal phospholipid neutralization from platelet neutralization or routine activated PTT testing
It is often necessary to perform both types of neutralization procedures (85597 and 85598) on the same sample because antiphospholipid antibodies are heterogeneous and may respond positively in one of the tests and not in the other
The hexagonal phospholipid procedure (85598) is also considered a confirmatory procedure when it is necessary to increase the phospholipid concentration in the reagent as compared with the platelet neutralization procedure
EXAMPLE
A patient’s coagulation screening tests reveal a prolonged PT, moderately elevated D-dimer level, decreased fibrinogen level, and decreased platelet count
In this example, thrombelastography is interpreted, comparison with previous study reports is done, relevant statistical variations are considered, clinically meaningful findings are identified, and the interpretation report is dictated
Code 85397 represents coagulation and fibrinolysis testing, functional assays that were not previously codifiable owing to the lack of a generic functional assay code
Code 85397 can be used for other proteins participating in coagulation and fibrinolysis
Code 85397 may also represent the “A Disintegrin and Metalloproteinase With a Thrombospondin type 1 motif, member 13 [ADAMTS13]” assay
ADAMTS13 (a von Willebrand factor cleaving protease) is a congenital or an acquired deficiency associated with thrombotic thrombocytopenic purpura and, more rarely, with the hemolytic uremic syndrome
As measurement of activity for proteases, ADAMTS13 has important clinical applications in the diagnosis of thrombotic thrombocytopenic purpura
Bone Marrow Aspiration, Bone Marrow Biopsy, and Bone Biopsy
CPT code 85097 is used to report the interpretation of a smear resulting from a bone marrow aspiration procedure
The smears are stained in a hematology laboratory or an office
Whether a differential cell count is performed or whether the findings are reported in a more descriptive manner, the same code applies
If an aspirate clot is processed as a cell block in the histology laboratory, the additional code 88305 is also reported
Codes 38220 and 38221 should be reported for the actual aspiration procedure and the actual bone marrow biopsy procedure, respectively
The interpretation of the biopsy specimen is reported with code 88305
When performed, the decalcification procedure is separately reported with code 88311
The following codes are for pathologic examination:
Code 85097 describes the examination of the bone marrow smear
Code 88305 describes the examination of the bone marrow cell block (also known as clot or particle section) prepared from the aspirate
Code 88305 describes the examination of the bone marrow biopsy specimen
Code 88311 describes the decalcification of the bone marrow biopsy specimen or bone biopsy specimen
Code 88313 describes the iron stain of bone marrow smear or clot section
If additional testing is performed to establish the diagnosis (eg, additional special stains or immunohistochemical techniques), other CPT codes may be reported as needed to describe the additional testing (eg, organism stains)
Transfusion Medicine
The Transfusion Medicine subsection (86850-86999) includes codes for transfusion-related antibody testing, autologous blood collection, processing and storage, and other processes now common in the preparation of blood donated for transfusion
EXAMPLE
During an orthopedic procedure, the patient’s blood was drawn and cytocentrifuged to separate the platelet-rich plasma from the platelet-poor plasma
The RBCs were injected into the operative site
In this case, Category III code 0232T is reported and includes a combination of procedures, ie, the collection of venous blood, cytocentrifuged to separate the platelet-rich plasma (fibrin) from the platelet poor plasma and RBCs, and any imaging guidance used for harvesting and/or injection
The placement/injection of the cells into the operative site is an inclusive component of code 0232T
It would not be appropriate to report code 86999, Unlisted transfusion medicine procedure, for obtaining and centrifuging the blood drawn
It is also not appropriate to report code 86985, Splitting of blood or blood products, each unit, to describe the derivation of the platelets
The parenthetical note following code 0232T also instructs that code 0232T is not to be reported with code 86965
It is also not appropriate to report code 36513 because therapeutic apheresis was not performed
EXAMPLE
A patient with a diagnosis of nonunion of a tibial fracture undergoes repair of the nonunion
Using a core needle and trocar, bone marrow aspiration into a 60-mL syringe was performed
Via a separate trocar insertion site, 35 mL of bloody aspirate was obtained, and the aspirate was prepared to obtain the platelet-rich cells (ie, hematopoietic stem cells and mesenchymal stem cells)
Next, the plate and screws were removed from the tibia
The platelet stem cells were then injected through a small stab incision into the tibial nonunionsite
In this example, Category III code 0232T should be reported for the injection into the operative site of the platelet-rich plasma containing the stem cells
The harvest of bone marrow and bloody aspirate from the right iliac crest into a 60-mL syringe is considered inherent in code 0232T
Code 0232T is reported in addition to the code for definitive tibial fracture nonunion repair (27724)
The CPT coding guidelines may differ from third-party payer guidelines
Eligibility for payment and coverage policy are determined by each individual insurer or third-party payer
For reimbursement or third-party payer policy issues, local third-party payers should be contacted
CODING TIP Code 0232T should be reported for the collection (venous blood or bone marrow aspiration), centrifuge of the specimen to derive the platelet-rich (including stem cell) plasma, and injection(s) of platelet-rich plasma
This is not a transfusion medicine service (86999, 86985)
Microbiology
Codes in the Microbiology subsection (87001-87999) include bacteriology, mycology, parasitology, and virology
When various microbiology testing procedures are reported, it is appropriate to designate, by separate entries, multiple procedures that are done on the same date
CODING TIP When separate results are reported for different species or strains of organisms, each result should be coded separately
Modifier 59 is used when separate results are reported for different species or strains that are described by the same code
The guidelines in the Microbiology subsection provide clear definitions of presumptive and definitive identification
Presumptive identification of microorganisms is defined as identification by colony morphology, growth on selective media, Gram stains, or up to 3 tests (eg, catalase, oxidase, indole, urease)
Definitive identification of microorganisms is defined as identification to the genus or species level that requires specific additional tests (eg, biochemical panels, slide cultures)
If additional studies involve molecular probes, chromatography, or immunologic techniques (87140-87158), they should be separately coded in addition to definitive identification codes
For multiple specimens or sites, modifier 59 is used
For repeated laboratory tests performed on the same day, modifier 91 is used
(Refer to Chapter 8 for further discussion of modifiers
)
The codes in the 87040-87077 series are intended to represent bacterial cultures
Specifically, codes 87040, 87045, and 87046 are intended to be reported for aerobic bacterial culture of blood and stool
Code 87070 is reported for aerobic bacterial culture of any other source except urine, blood, or stool (eg, other body fluid or wound drainage)
Codes 87071, 87073, and 87075-87077 represent codes for aerobic and anaerobic techniques
These codes are also intended to be reported for presumptive and definitive identification of isolates
Screening cultures are reported with codes 87081 and 87084
Screening cultures are cultures used for the detection of a specific potential pathogenic organism (eg, a throat culture used to detect group A Streptococcus only)
CODING TIP If the requisite steps to obtain quantitative aerobic culture results were performed, a negative finding does not alter the use of code 87071
Codes 87086 and 87088 are intended to be used to report bacterial detection, quantitation, and presumptive identification of isolate(s) in urine specimens
Code 87086 is reported for the initial urine culture and quantitation (if growth occurs) and code 87088 for the presumptive identification of each potential pathogenic isolate
Urine cultures resulting in no growth are reported by using code 87086
EXAMPLE:
A urine sample is collected for urine culture
The sample is placed in a self-contained culture system
Urine is placed in a tube
A culture slide covered with agar media is dipped into the sample
The sample is then incubated
After incubation, the specimen is compared with a density chart and results are reported
In this case, code 87084 is reported to represent identification of the presence of bacteria and estimation of the number of organisms based on a density chart
This service is different from performing a quantitative colony count for the specimen (eg, 87086)
For example, in a non-acute setting it may sometimes be requested that a urine specimen be cultured and screened using a density plate
The density chart provides an estimation to allow further testing for quantitative and/or identification (eg, 87077, 87088, 87186)
If the culture yields a negative result and no additional testing is performed, no additional codes should be reported
Codes 87101-87107 describe fungal cultures
The appropriate code from this series is selected on the basis of the source of the specimen
Code 87101 describes fungal culture of the skin, hair, or nail
Code 87102 is intended for reporting another source (except blood)
Code 87103 describes a fungal culture of the blood
Code 87106 is intended to be reported for definitive identification of each fungal organism
This code is reported in addition to codes 87101, 87102, and 87103, when appropriate
If definitive identification of more than 1 fungus is performed on a single specimen, it would be appropriate to report this code more than once per specimen
Again, code 87106 is intended to be reported for each organism definitively identified
Code 87107 is intended to be reported for mold cultures definitively identified
Culture typing is reported with codes in the 87140-87158 series
The appropriate code is selected on the basis of the method of testing, eg, immunofluorescence, gas-liquid chromatography, or high-performance liquid chromatography
Codes 87168, 87169, 87172, 87177, and 87209 are intended to report parasite testing
Code 87015 is not reported in conjunction with code 87177, Ova and parasites, direct smears, concentration and identification, because the concentration step is included in code 87177
Susceptibility studies are reported by means of codes 87181-87190
The appropriate code is selected on the basis of the method of testing (eg, disk method, enzyme detection)
Code 87187 is reported in addition to code 87186 or 87188
Codes in the 87205-87210 series are used to report various smears with interpretation
CPT code 87205 is the appropriate code for reporting a Gram stain
A Gram stain is a differential stain used to demonstrate the staining properties of all bacterial types
The Gram stain confirms the presence of bacteria and their cell type
It is appropriate to designate multiple procedures done on the same date by separate entries
Consider the following example:
EXAMPLE
A Gram stain is performed on the primary specimen in addition to an aerobic and anaerobic definitive bacterial wound culture
Additional identification methods are performed to determine the specific species within the organism group
Antibiotic sensitivity studies (minimum inhibitory concentration) are also performed
In this case, the Gram stain (87205), the aerobic bacterial wound culture (87070), the anaerobic wound culture (87075), the additional identification methods (87076 and/or 87077), and the antibiotic sensitivity studies (eg, 87186) should be separately reported
Within the Microbiology subsection, codes 87260-87904 and 87906 are specifically used for reporting the detection of infectious agent antigen
These codes are intended for the primary source only
For similar studies on culture material, codes 87140-87158 are used
The notes preceding the codes for infectious agent antigen detection direct users to the Immunology subsection codes 86602-86804 for the detection of antibodies to infectious agents
Included in codes 87260-87906 are separate code families based on the method used
Within each code family, the organisms listed represent those currently detectable by the specific method indicated
General method codes are included in each code family and are to be reported when there is no agent-specific listing for the method used
For example, code 87299 is used to report the detection of an infectious agent by immunofluorescent antibody technique when testing for an organism other than those specified in codes 87260-87290
Table 6-3 indicates the specific code families and methods available for reporting testing for the detection of infectious agent antigen
TABLE 6-3 Methods and Code Ranges
Method
Code Range
Immunofluorescent technique 87260-87300
Enzyme immunoassay technique 87301-87451
Nucleic acid (DNA or RNA) 87470-87801,87901-87906
Immunoassay with direct optical observation 87802-87899
In the Microbiology subsection, codes 87501, 87502, and 87503 are used to report the assays that detect infectious agents, such as the molecular methods for influenza virus, including the specific method used and agent detected
Add-on code 87503 should be reported in conjunction with code 87502
Code 87901 is used to report genotype analysis of an infectious agent by nucleic acid (DNA or RNA) in the HIV-1 protease and reverse transcriptase genomics regions
Code 87906 is reported for other regions
The use of HIV-1 genotyping of other regions, such as the integrase region, may be helpful in optimizing the treatment regimen for a patient with HIV infection
Code 87906 is a resequenced code that is out of numeric order
Cytopathology
Codes 88104-88199 are used to report various cytopathology procedures
Separate code series are available for reporting the following:
Cervical or vaginal cytopathology: 88141-88155, 88164-88167, 88174, 88175
Cytopathology of fluids, washings, or brushings (except cervical or vaginal): 88104-88106
Cytopathology, concentration technique: 88108
Cytopathology, selective cellular enhancement technique: 88112
Cytopathology smears from any other source (other than cervical or vaginal, or fluids, washings, or brushings): 88160-88162
Cytohistologic studies of fine-needle aspirate: 88172, 88177, 88173 (codes 10021 and 10022 for procurement are discussed in the Surgery section under the heading of General
)
EXAMPLE
A pathologist performs the procedures represented by and reports codes 88141 and 88175 on the same slide on the same date of service
In this case, when reporting Pap smear procedures, the code that describes the specific cytopathology methods used should be chosen
When additional services are provided, code 88141 is treated as an additional code and should be reported in addition to the code for the specific cytopathology methods
Code 88141 may be reported in conjunction with code 88175
Similarly, when services described by code 88155 are performed, they should also be separately reported
CODING TIP If an automated screening procedure fails, it provides no information and testing is essentially not performed
Therefore, it is not appropriate to report a laboratory test that was not performed, regardless of whether the sample was unacceptable or the analyzer failed
Cytopathology services for fluids, washings, or brushings (except cervical or vaginal) are reported with the codes in the 88104-88106 series
Code 88104 is used to report cytopathology smears of fluids, washings, or brushings (except cervical or vaginal) with interpretation
Code 88106 is reported when only the filter method is used and includes interpretation
Code 88107 was deleted in CPT 2012
To report smears and simple filter preparation, codes 88104 and 88106 are used
Cytopathology smears from any other source (except cervical or vaginal
except fluids, washings, or brushings) are reported with codes 88160-88162
Code 88160 is used to report cytopathology smears, screening, and interpretation
Code 88161 is reported for preparation, screening, and interpretation of cytopathology smears
Code 88162 describes an extended study involving more than 5 slides and/or multiple stains
Codes for concentration (88108) and for concentration and enrichment techniques (88112) are not specimen source-specific except that they should not be used for cervicovaginal cytology
The primary uses for these codes currently are the cytocentrifuge techniques (88108) and the thin-layer techniques (88112)
Of note, 1 of the thin-layer techniques currently uses a filter transfer technique
However, this does not suggest that this technique should be reported with code 88106
Neither of these codes should be used for fine-needle aspirate specimens because this service is inclusive of the fine-needle aspirate code 88173
An example for use of the 88160 series of codes is to report direct smear examinations for sputum, vesicle scrapings, nipple discharge smears, and other specimens not fulfilling the other cytologic code series (eg, not a fine-needle aspiration, fluid, brushing, or washing, and not analyzed by concentration or concentration and enrichment techniques)
Although code 88162 is used for extended cytologic study requiring the analysis of more than 5 slides and/or multiple routine stains, this code is applicable only to studies that do not fulfill the criteria for the other cytologic code series
The Bethesda System
The Bethesda System of reporting is a format for reporting cervical-vaginal cytologic diagnoses
This format for reporting provides uniform diagnostic terminology to facilitate unambiguous communication between laboratory professionals and clinicians
The Bethesda System has the following 4 basic elements:
Specimen type (conventional smear vs liquid-based preparation vs other)
Statement of specimen adequacy—A statement of specimen adequacy is an integral part of the report
Specimens may be designated as satisfactory for evaluation or unsatisfactory for evaluation
(The reason should be specified, and whether the specimen was rejected and not processed or processed and not evaluable should be stated
)
General categorization—The general categorization is included to aid clinicians in prioritizing cases for review or to assist laboratory personnel in compiling statistical information
This categorization should not be used as a substitute for a descriptive diagnosis
General categorizations include negative for intraepithelial lesion
epithelial cell abnormality, see interpretation or result
and other
Interpretation or result—In the Bethesda System, descriptive diagnoses are grouped into categories: negative for intraepithelial lesion or malignancy (including organisms and other nonneoplastic findings), other malignant neoplasms, and epithelial cell abnormalities
Ancillary testing and automated review, if performed, are also included in the 2001 format for the Bethesda System
Codes 88141-88155, 88164-88167, 88174, and 88175 are used to report cervical or vaginal screening by various methods and to report interpretation services
Codes 88150-88154 are used for manual screening of conventional Pap smears that are reported by a non-Bethesda System of reporting
Codes 88164-88167 are used for manual screening of conventional Pap smears that are reported by means of the Bethesda System of reporting
Codes 88142 and 88143 are used for manual screening of liquid-based specimens processed as thin-layer preparations that are reported by any system of reporting (Bethesda or non-Bethesda)
Codes 88174 and 88175 are used for automated screening of liquid-based specimens that are reported by any system of reporting (Bethesda or non-Bethesda)
The 4 code families for reporting Pap smear services include the following:
88142, 88143, 88174, 88175 (Thin-layer preparation, any system of reporting, manual or automated screening)
88147, 88148 (Conventional Pap smears, primary screening by automated system)
88150-88154 (Conventional Pap smears, non-Bethesda reporting, manual screening)
88164-88167 (Conventional Pap smears, Bethesda system of reporting, manual screening)
CODING TIP Negative Pap smears (including smears reviewed for quality control purposes) that do not require interpretation should not be coded with the interpretation code 88141
No separate listing in the CPT code set exists to report Pap smears reviewed for quality control purposes
When Pap test procedures are reported, the one code that describes the screening method used should be chosen from the preceding code families
Codes 88141 and 88155 should be reported in addition to the screening code chosen when additional services are provided that may be of a professional interpretive nature
Manual rescreening requires a complete visual reassessment of the entire slide initially screened by an automated or a manual process
A manual review represents an assessment of selected cells or regions of a slide identified by initial automated review
Code 88141 should be used to report interpretation of a Pap test that is interpreted to be abnormal by personnel performing the initial screening, including tests interpreted as showing “suspicious” or malignant cells, tests showing epithelial cell abnormality (eg, atypical cells of undetermined significance), and tests showing cellular changes simulating epithelial cell abnormality such as repair, radiation effect, and cellular changes associated with viral infection
In addition, this code is not reported for negative Pap tests that are reviewed solely for quality control purposes
Table 6-4 is provided to summarize the Pap test code families
TABLE 6-4 CPT Codes and Procedures for Pap Smears
CPT Code
Service or Procedure Described
88141 Interpretation (used in conjunction with codes 88142-88154, 88164-88167, 88174, 88175), any reporting system
88142-88143 Automated thin-layer preparation, manual screening, any reporting system
88147-88148 Conventional Pap smears, primary screening by automated system
88150, 88152, 88153, 88154 Conventional Pap smears, manual screening, non-Bethesda reporting
88155 Add-on code definitive hormonal evaluation (used in conjunction with codes 88142-88154, 88164-88167, 88174, and 88175)
88164, 88165, 88166, 88167 Conventional Pap smears, manual screening, Bethesda system of reporting
88174, 88175 Automated thin-layer preparation, automated screening, any reporting system
Pap indicates Papanicolaou
Fine-Needle Aspiration
Codes 10021 and 10022 are used to report the technique of fine-needle aspiration—the actual procedure performed during the aspiration
Cross-references related to the use of these codes are found in the specific anatomic sections throughout the CPT code set
A fine-needle aspiration is performed when material is aspirated with a long, slender needle and the cells are examined cytologically
This procedure is in contrast with a biopsy, in which a small piece of tissue is obtained and examined for histologic architecture
The code descriptors for fine-needle aspiration procedures are reviewed in the following paragraphs
10021
Fine needle aspiration
without imaging guidance
10022
with imaging guidance (For radiological supervision and interpretation, see 76942, 77002, 77012, 77021
)
Code 10021 is reported if the fine-needle aspiration is performed on superficial tissue
Code 10022 is reported for a fine-needle aspiration of deep tissue under radiologic guidance
As indicated by the parenthetical note following code 10021, this code describes the needle aspiration procedure only
the radiologic guidance is reported separately by means of code 76942, 77002, 77012, or 77021, depending on the type of guidance used
Codes 10021 and 10022 include the preparation of smears, if smears are prepared
(Refer to Chapter 5 for further discussion of radiologic guidance
) Retrieval and collection of ductal epithelial cells obtained through the ductal lavage procedure via insertion of microcatheters into the mammary ducts are reported with code 19499
Codes 88172, 88177, and 88173 remain in the Pathology and Laboratory subsection and are used to report the evaluation of fine-needle aspirate specimens
These codes appear in the CPT code set as follows:
88172
Cytopathology, evaluation of fine needle aspirate
immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site
88177
immediate cytohistohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site
88173 interpretation and report
A cytopathologic evaluation episode reported by codes 88172 and 88177 represents a complete set of cytologic material submitted for evaluation and is independent of the number of needle passes or slides prepared
A separate evaluation episode occurs if the provider obtains additional material from the same site, based on the prior immediate adequacy assessment, or a separate lesion is aspirated
One unit of code 88173 is reported for the interpretation and report from each anatomic site, regardless of the number of passes or evaluation episodes performed during the aspiration procedure
The material aspirated is frequently examined microscopically immediately to ensure that diagnostic material is present
Often this step is done to provide a preliminary diagnostic assessment so that a repeated operative procedure is not necessary
Codes 88172, 88173, and 88177 are used to report these services
When a final definitive interpretation and written report are issued, the definitive interpretation and written report should be reported with code 88173
If a physician or pathologist performs both services (immediate evaluation to determine the adequacy of the specimen and the interpretation and report), it would be appropriate to report both codes, 88172 and 88173, for the services provided
As noted, these codes include the procedures represented by other cytopathology codes (eg, for direct smears, cytocentrifuge, and thin-layer preparations)
Additional coding for an accompanying cell block preparation (88305) and any special studies, including special or other immunohistochemical stains, may also be appropriately reported
Cytogenetic Studies
Cytogenetics is the study of chromosomes by light or fluorescent microscopy to rule out an inherited (constitutional) or acquired chromosomal abnormality
Cytogenetics professionals examine preparations for microscopically visible chromosomal changes, deletions, or additions
Any deviation, deletion, or addition to the 23 human pairs of chromosomes is considered abnormal
Identification of where and when a chromosomal alteration or abnormality occurs provides vital information for prenatal testing, diagnosing congenital disorders, and diagnosing and assessing the treatment of certain cancers
Genetic analysis is also used to predict the best medication or dosage for treating a specific disease
CODING TIP In cytogenetics, the term analysis incorporates 2 tasks: (1) a count of all chromosomes in the cell to determine whether the cell contains a normal or abnormal number of chromosomes and (2) determination of a karyotype
A karyotype is the complete set of all chromosomes of a cell of any living organism
A karyotype analysis usually involves stopping cell division (mitosis) and staining the condensed chromosomes
When stained, the mitotic chromosomes have a “banded” structure that unambiguously identifies each chromosome of a karyotype
Staining methods (88261-88264, 88283) may result in banding on the chromosomal arms (chromatids)
the chromosomes can then be identified according to their banding pattern
Codes 88271-88275 represent other techniques in addition to banding that allow for genetic evaluation of chromosomes
Chromosomal analysis for breakage syndromes (88245, 88248, 88249) refers to studies performed to identify a group of rare genetic disorders
A clastogen is any environmental agent, including carcinogens, that causes damage to genetic material
Sister chromatid exchange (88245) is a sophisticated cytomolecular technique commonly applied in a search for clastogenicity or genotoxicity
Therefore, sister chromatid exchange is used to help determine whether the chromosomes and, thus, DNA have undergone genetic damage compared with a control group
CODING TIP By definition, chromosome counts and karyotypes are inherent in a complete analysis (88264)
It would be inappropriate to use code 88264 with a code (eg, 88262) that includes a count and/ or karyotype
The interpretation and report of the cytogenetic service for codes 88264 and 88262 is additionally reported with code 88291
Code 88264 describes a complete analysis of the chromosomes, as is done in cancer studies because mosaicism (2 or more cell populations that differ in genetic makeup) is common
In prenatal diagnosis, structural chromosome mosaicism is so low relative to numeric mosaicism that it is detected through the simple counting of the chromosomes
For code 88264, in cytogenetics, the term analysis incorporates 2 tasks: (1) a count of all chromosomes in the cell to determine whether the cell contains a normal or abnormal number of chromosomes and (2) determination of a karyotype
Code 88285 describes the work of all additional cells counted and, therefore, should be reported once
The descriptor indicates the analysis of additional cells (plural)
For example, if 10 cells are counted instead of 5 (88261), code 88285 would not be reported 5 times to account for the additional cells
In this instance, code 88285 is reported once
EXAMPLE
In a case for cytogenetic analysis, 40 cells were submitted
In this case, code 88262 would be reported once, and the additional cells to be scored would be reported with code 88285, Chromosome analysis
additional cells counted, each study
Code 88285 does not specify the number of additional cells and is reported once regardless of the number of additional cells scored
Surgical Pathology
Codes 88300-88309 are used to report surgical pathology
When these codes are reported, services include accession, examination, and reporting
They do not include the services designated in codes 88311-88399 or molecular pathology interpretations by the pathologist, which are coded in addition when provided
Understanding the pathology service definition is necessary for proper use of the surgical pathology codes
The unit of service for codes 88300-88309 is the specimen
A specimen is defined as tissue or tissues submitted for individual and separate attention requiring individual examination and pathologic diagnosis
When material received for pathologic examination comprises multiple specimens, each specimen is considered a single unit of service and is to be reported by using a single code
Codes 88302-88309 should not be reported for the same specimen as part of Mohs surgery
The responsibility for correct coding lies with the Mohs surgeon
If a Mohs surgeon submits a specimen to a pathologist, the pathologist is entitled to report the appropriate codes for the services provided
The Mohs surgeon is prohibited from billing for the Mohs procedure in that situation
It would be inappropriate for the Mohs surgeon to report Mohs micrographic surgery codes with submission of tissue
However, it is appropriate for the pathologist to code for his or her services provided
More than 170 surgical pathology specimens are assigned individual CPT codes
Inevitably, some specimens and procedures will be encountered in practice that are not included in these lists
Unlisted specimens should be assigned the code that most closely reflects the work involved when the unlisted specimen is compared with other specimens assigned that code
Because code selection for unlisted specimens is based on comparison of work with the work for other listed specimens, coders responsible for assigning the surgical pathology code to an unlisted specimen should communicate with the physician regarding appropriate code selection
The following examples demonstrate appropriate coding:
EXAMPLE 1
Two separate skin lesions are submitted in a single container
One of these specimens is separately identified by a suture
Accompanying specimen information indicates “skin biopsy without suture from the left cheek
skin biopsy with suture from the right cheek
” The work related to each of these separately identified specimens is coded as 88305 (2 units of service)
EXAMPLE 2
Two separate skin lesions are submitted in a single container
however, they are not separately identified
This is 1 specimen and is coded as 1 unit of service with code 88305
Code 88300 is reported for any specimen that, in the opinion of the examining individual, can be accurately diagnosed without microscopic examination
Code 88302 is used when gross and microscopic examination are performed on a specimen to confirm identification of a presumptively normal specimen and absence of disease
EXAMPLE 3
The tissue (eg, uvula, omentum) received for surgical pathology evaluation is not listed in the 88302-88309 surgical pathology code series
In such cases, the unlisted specimen should be reported with the code that most closely reflects the physician work involved when compared with the work for other specimens assigned to that code
EXAMPLE 4
A pathologist received gallbladder material for pathologic examination comprising multiple specimens for individual and separate attention and individual examination and pathologic diagnosis
In this case, the gross and microscopic examinations for each specimen are considered 1 unit of service
The appropriate surgical pathology code should be reported
Codes 88300-88309 do not include the services described by codes 88311-88388
CODING TIP The unit of service for codes 88300-88309 refers to the specimen
Codes 88304-88309 describe all other specimens requiring gross and microscopic examination and represent additional ascending levels of physician work
Codes 88302-88309 are specifically defined by the assigned specimens
As stated, codes 88300-88309 do not include the services described by codes 88311-88388
Codes in the 88311-88388 series represent additional surgical pathology services
The unit of service for codes in this section is the specimen, but unlike the tissue pathology section, the specimen submitted for special studies may be tissue or any body fluid or blood
These codes may be used alone or in addition to the code(s) reported for the primary surgical pathology services
Additional services include the following:
Decalcification procedure
Special stains
Determinative histochemistry or cytochemistry
Frozen sections
Immunohistochemistry
Immunofluorescent studies, direct or indirect
Electron microscopy
Morphometric analysis
Microdissection
Nerve-teasing preparations
Tissue in situ hybridization
Protein analysis of tissue by Western blot
As in coding for gross and microscopic examinations of each specimen, a separate code should be used to report each additional service provided
For example, each antibody used in an immunohistochemical study of a specimen should be separately reported with code 88342
The unit of service for special studies, like basic gross and microscopic evaluation, is the specimen
Because multiple individual and distinct special stains, immunohistochemical antibodies, and molecular probes are reported by means of the same CPT codes, the unit of service is further categorized appropriately
Hence, special (nonimmunohistochemical) stains are coded per special stain, per specimen
immunohistochemistry is coded per separately identifiable antibody, per specimen
and in situ hybridization is coded per separately identifiable molecular probe, per specimen
Table 6-5 is provided as an alphabetic reference for code assignment for surgical pathology specimens

TABLE 6-5 Surgical Pathology Reference,

In Vivo (eg, Transcutaneous) Laboratory Procedures
Transcutaneous methods for detecting carboxyhemoglobin and methemoglobin that provide point-of-care test results without drawing blood (ie, without removing the specimen from the person) are reported with the 88720-88749 code series

When transcutaneous testing is performed, spectrophotometric methods using transcutaneous reflectance techniques can be used for detecting and quantitatively measuring hyperbilirubinemia, carboxyhemoglobinemia, and methemoglobinemia
Spectrophotometry is based on the principle that substances absorb or reflect and transmit light in characteristic ways
Spectrophotometric blood analysis systems differ substantially in their operation and use
Different systems include “CO-oximeters” and noninvasive oximeters, such as ear and pulse oximeters
Although “CO” is the chemical symbol for the carbon monoxide molecule, “CO-oximetry” actually encompasses measurements of hemoglobin and oxygen gas exchange, including oxyhemoglobin and oxygen saturation
CO-oximetry is also used in the determination of carboxyhemoglobin and methemoglobin levels
CODING TIP Transdermal oxygen saturation testing is reported by means of codes 94760-94762
Code 88720 is used to report transcutaneous quantitative testing for the detection of hyperbilirubinemia
The transcutaneous reflectance measurement on the neonate’s skin using skin characteristics such as collagen, melanin, hemoglobin, and bilirubin, provides digital assessment of the amount of yellow pigment present in the skin
When the device is placed against an infant’s skin (typically the forehead), the device displays a calculated serum total bilirubin level in (mg/ dL)
Codes 88740 and 88741 use a transcutaneous light reflectance method different from that reported with code 88720
Code 88740 describes transcutaneous quantitative carboxyhemoglobin testing and includes all services during any one day
Transcutaneous quantitative carboxyhemoglobin measurement is performed, for example, in the determination of carbon monoxide poisoning
Code 88741 describes transcutaneous quantitative methemoglobin, for example, in the diagnosis of acquired or inherited methemoglobinemia (an abnormal form of hemoglobin)
In elevated concentration, functional anemia and tissue hypoxia may occur
CODING TIP Report code 0233T for wavelength fluorescent spectroscopy of advanced glycation end products (skin)
It would not be appropriate to use unlisted code 88749 for such an analysis
Code 82375 is used to report quantitative in vitro determination of the carboxyhemoglobin level
Code 88742 is used for transcutaneous quantitative methemoglobin, for example, in the diagnosis of acquired or inherited methemoglobinemia (an abnormal form of hemoglobin)
Code 83050 is used to report the quantitative determination of methemoglobin
CODING TIP Because transcutaneous pulse CO-oximetry is a continuous and noninvasive monitoring method, codes 88740 and 88741 are reported only once per date of service
Therefore, it is not appropriate to append modifier 59 or modifier 91 to code 88740 or 88741
However, if repeated transcutaneous bilirubin testing is performed later on a given date of service, it would be appropriate to append modifier 91 to code 88720 for subsequent analyses
Reproductive Medicine Procedures
In vitro fertilization involves many complex laboratory procedures performed during 1 to 7 days
These procedures involve the male and female gametes and the subsequent embryos that develop
The CPT nomenclature initially had only 1 code to describe the laboratory procedures used from the time the oocyte was aspirated from the ovary until the embryo was transferred to the uterus or was cryopreserved
Codes in the subsection are intended to describe the different work components involved as the variety and complexity of assisted reproductive technology expanded
Codes in the reproductive medicine subsection are intended to be used to report oocyte or embryo culture and fertilization techniques (89250, 89251, 89268, 89272, 89280, and 89281)
oocyte or embryo biopsy techniques (89290 and 89291)
and freezing, thawing, and storage techniques (89258, 89259, 89335, 89342-89344, 89346, 89352-89354, and 89356)
These nonphysician procedures are performed in highly specialized clinical laboratories and should be reported separately from additional services performed by physicians or other qualified health care professionals
Code 89258 is intended to be used for reporting cryopreservation of embryos
Code 89259 is used for cryopreservation of sperm
CODING TIP Extended culture of oocyte(s) or embryo(s) is reported by using code 89272
Sperm must be evaluated and/or prepared for use in vitro fertilization, intrauterine insemination, and, in some cases, for diagnostic purposes by isolation using laboratory methods
Simple preparations or complex preparations may be used on the basis of the results of semen analysis
The samples are given to the laboratory by the male of an infertile couple
The choice of sperm preparation is based on motility, concentration, and cellular components of the sample previously examined by analysis (89320)
Code 89320 represents automated, differential testing for reporting a basic semen analysis that includes analysis of volume, count, motility, and differential for the measurement of the ejaculate volume, sperm concentration, and motility
To differentiate, code 89322 involves analysis for the 4 criteria described in code 89320, with a sperm morphologic analysis in which a stained slide is prepared and morphologic assessment of several hundred individual sperm is performed
Each sperm analyzed must have inspection of head, neck, and tail
This system of detailed scrutiny results in classification of many sperm as abnormal, compared with the less detailed analysis reported with code 89320, and results in a more accurate determination of the ability of sperm to fertilize an egg
Codes 89320 and 89322 would not typically be reported together because code 89320 is the basic analysis, which, when evaluated, may require the patient to return to provide an additional sample for a more detailed analysis of the sample characteristics
Retrograde ejaculation is a condition in which the ejaculate is diverted to the bladder instead of the urethra
Laboratory testing involves the patient providing an ejaculated specimen for analysis similar to a complete semen analysis such as represented by code 89320 but includes a second specimen to be analyzed
After ejaculation, urine is collected and centrifuged, and a second semen analysis is performed
Code 89331 describes assessment of retrograde ejaculate, requiring processing and analysis of an antegrade ejaculate and a urine specimen
To differentiate, simple sperm identification in urine is reported by using code 81015
Other Procedures
This subsection reports other procedures in the 89049-89240 series
Codes 89100 and 89105 have been deleted
To report the associated procedures, codes 43756 and 43757 are used
Codes 89130-89141 have also been deleted
Procedures are reported with codes 43754-43755
The codes used for reporting gastric intubation and aspiration procedures, which align with corresponding procedures for duodenal intubation and aspiration, are located in the Digestive System subsection of the Surgery section
The laboratory component of gastric acid analysis is represented by code 82930
BOOK III COMPLETED

Integumentary System Chapter Topics Integumentary System Format Skin, Subcutaneous, and Accessory Structures Nails, Pilonidal Cyst and Introduction Repair (Closure) Burns Destruction Breast Procedures Learning Objectives After completing this chapter you should be able to 1 Describe the format of the …

Axillary nodes lymph nodes located in the armpit splenectomy excision of the spleen WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY FOR YOU FOR ONLY $13.90/PAGE Write my sample splenoportography radiographic procedure to allow visualiztion of the …

LOCATION: Outpatient, Hospital PATIENT: Tom White SURGEON: David Barton, MD RADIOLOGY: Morton Monson, MD PROCEDURE: Transesophageal echocardiogram INDICATIONS: Evaluation of the aortic valve considering the stenosis that was not well-documented angiographically PROCEDURE: The patient received 2 mg of Versed, and …

Surgery Guidelines and General Surgery Chapter Topics Introduction to the Surgery Section Notes and Guidelines Unlisted Procedures Special Reports Separate Procedure Surgical Package General Subsection Learning Objectives After completing this chapter you should be able to 1 Understand the Surgery …

David from ajethno:

Hi there, would you like to get such a paper? How about receiving a customized one? Check it out https://goo.gl/chNgQy