88321 – Outside slides only
88323 – Outside slides + prepared slides
88325 – Outside slides + review of record + prepared slides if needed
REPORTING GUIDELINES
• Consultation codes include review of special stain, IHC, immunofluorescence, and any other special procedure slides and test data prepared and initially interpreted at the referring facility.
• Any number of specimens can be included. The number of individual specimens received for review will not change the code.
• Clinical history, pathologic diagnosis, and complexity do not affect the code.
• Unit of service is the outside surgical pathology case or cytopathology case, which can include multiple specimens for review.
o Unit of service is not the specimen as it is for primary surgical pathology codes 88300-88309; instead, it’s the case.
o Each individual case that is included for consultation is 1 unit.
• For special studies ordered by the consultant from the lab where they practice, separately report the applicable add-on procedure code (88312, 88342, etc.). Most of the time a modifier is needed to identify the additional procedure.
Code 88321 - Consultation and report on referred slides prepared elsewhere.
• Code 88321 when the consultant receives a set of slides and does not require any additional preparations from the consulting lab.
Code 88323 - Consultation and report on referred material requiring preparation of slides.
• Code 88323 if additional routine preparations are needed; re-cuts, deeper sections, or additional stains or preparations performed by the consulting facility.
o Documentation should support medical necessity for the additional preparations.
• A separate charge for added routine-stained slides cannot be billed.
• Special procedures are separately chargeable with consult cases when they are prepared or repeated by the lab at which the consultant practices.
Code 88325 - Consultation, comprehensive, with review of records and specimens, with report on referred material.
• Code 88325 when patient records beyond the outside pathology report and associated slides/material are considered by the consultant to make the diagnosis (review of chart, lab results, oncologist consultations, etc. Must include more than pathology reports).
• Special procedures are separately chargeable with consult cases when they are prepared or repeated by the lab at which the consultant practices.
• The sole criterion to code 88325 is the presence of patient records beyond the outside pathologist’s report and includes a comprehensive review of the patient’s records, more than just a cursory review, and that the consultation process objectively integrates the information to arrive at a diagnosis in conjunction with the pathology specimens received.
• Documentation should be clear that the outside material was incorporated into the process of arriving at a diagnosis, beyond just having received one or two reports or slides.
ADDITIONAL BILLING NOTES
• A formal consultative medical report must be prepared and issued by the pathology consultant to warrant a fee being billed to a patient, a payer or insurer, or an outside physician or facility.
• The slides should be identified and briefly described, and include a final diagnosis for each individual specimen received.
• If reviewed, documentation should include any information beyond the outside pathologist’s report incorporated in the consultation diagnosis.
• Clearly document what is done with tissue block(s) from the outside facility.
• Consultation reports often include impressions from special stains, IHC, etc., and it must be very clear whether the preparation was developed at the outside facility or the consulting lab. When billing for additional procedures ordered from the consulting lab, document:
(a) what it is that was ordered from the lab;
(b) why that item is medically indicated for the case; and
(c) result.
• The date of service is the date the request is received. The consult request should be time stamped or signed with the date/time.
CPT copyright 2024 American Medical Association. All rights reserved.
