Pathologists, as any other physician, are required to report the code(s) which most accurately describes the medical service that has been rendered regardless of where it is in the CPT® book. The AMA notes in CPT: “It is important to recognize that the listing of a service or procedure and its code number in a specific section of the book does not restrict its use to a specific specialty group. Any procedure or service in any section of this book may be used to designate the services rendered by any qualified physician or other qualified health care professional.”
Code 76098 (Radiologic examination, surgical specimen) in the radiology section is one example. Code 76098 is reported by a pathologist to indicate that the film was reviewed and used to assist in orienting the specimen and/or in localizing the suspect lesion, calcification deposit, etc. to ensure that the most appropriate area of the specimen is sectioned for microscopic examination and diagnosis. The College of American Pathologists confirms that code 76098 may be reported for this service (CAP Today, 2003). Per the AMA's CPT 2007, the descriptor for code 76098 does not include “interpretation and report,” but simply states “radiological examination, surgical specimen.” It is not expected that a formal “interpretation” be documented in the report for this service; it is understood the radiograph is reviewed and used to contribute to the diagnosis and treatment of the patient.
Documentation typically includes a statement in the Gross Description but can be included in other sections of the report. The documentation must indicate that the accompanying x-ray was reviewed by the pathologist, the objective of the review, and what action was taken.
Example: An accompanying radiograph with the encircled area of concern is reviewed. The specimen is oriented as per the requisition: one stitch-anterior and two stitches-posterior. Margins are inked for microscopic review.
Code 76098 does have a professional and a technical component. Since the mammography would not be performed by the pathologist, modifier -26 (Professional Component) should be appended to the CPT code. Some carriers may deny as “paid to another provider” in which case modifier-77 (repeat procedure by second physician) can be appended to differentiate the charge from the radiologist.
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