1. Pathology and Laboratory
If you are working in a laboratory or for a pathologist, this is the code section you’re going to become most familiar with on the job. Some of these procedures also are done in an office setting, but in a very limited way, depending on what kind of lab set up the office has.

2. CPT®
CPT® copyright 2016 American Medical Association. All rights reserved.
Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
CPT is a registered trademark of the American Medical Association.

3. Regulatory Terms Clinical Laboratory Improvement Amendment (CLIA)
CMS issues a waiver
Approximately 80 tests
Little risk of error
For more info., see
Physicians are allowed to perform only a limited number of lab tests in the office, since To do so they must apply for a Clinical Laboratory Improvement Amendment (CLIA) waiver. CMS regulates all laboratory testing to ensure quality. The waiver allows physicians to perform certain tests that CMS considers to be so simple there is very little risk of error in performing and interpreting them. The provider has to enroll in the CLIA program, pay a fee, and follow the manufacturers’ instructions when performing the test. There are approximately 80 tests under this waiver. There’s a CMS Web address listed on your slide where you can find the latest list of CLIA-waived tests.

4. Regulatory Terms Advance Beneficiary Notice (ABN)
Non covered laboratory tests
Patient is responsible for payment
For more info., Web search “CMS-R-131”
CMS also has specific guidelines as to which laboratory tests are covered for Medicare beneficiaries. When a test is ordered that is not a covered benefit, the provider is required to have the patient sign an Advance Beneficiary Notice (ABN). This notice specifies the test is not covered and the patient is aware that he or she will be responsible for payment of the testing. ABN’s are required for any service provided that is not a covered benefit of Medicare. To find a copy of the latest ABN and instructions for use, visit the CMS website.

5. Modifiers 90 Reference or Outside Laboratory
Billed by physician but performed by an outside laboratory
91 Repeat clinical diagnostic lab test
Same test same day
Not used if due to error
Not used if there is a better code for a series of tests
Now let’s talk about modifiers that can be used for laboratory services. The modifiers are listed in Appendix A of CPT®, along with a brief description of how they’re used. The modifiers are listed numerically, and the ones we use for laboratory services are at the end of the list: 90, 91, and 92. It may also be appropriate to use 99, which indicates the use of multiple modifiers. Let’s take a look at these.
Modifier 90 represents reference or outside laboratory. In a situation where physicians are billing for the lab, but the lab service is being performed outside of their office by another provider, they would want to append modifier 90 to the code for the lab service. This tells the payers that even though a physician is billing for it, he or she is not actually the one performing the service.
Modifier 91 is repeat clinical diagnostic lab test. There are specific requirements that must be met to use this repeat lab test modifier. In some situations, it may be necessary to repeat the same laboratory test on the same day. An example is testing the levels of a chemical that might be toxic to the patient, and it is critical to see if the levels are increasing or decreasing. Modifier 91 cannot be used if the repeated test is due to a problem with the specimen or equipment. The modifier may not be used when there are other codes that better describe a series of test results, such as with a glucose tolerance test, where blood is drawn at several intervals to measure the glucose level.

6. Modifiers 92 Alternative laboratory platform testing Portable test kit
Single use disposable chamber
99 Multiple modifiers
Modifier 92 is for alternative laboratory platform testing. This is testing done with a kit containing a single use, disposable chamber. It’s a very specific testing method. It can be taken to the patient to be used, or it could be performed in the lab. It doesn’t matter where the testing takes place; it’s the device. If this type of device is being used, you append modifier 92 to the lab code.
Modifier 99 describes multiple modifiers. If you have a situation where you’re using multiple modifiers, its okay to use modifier 99 and then list the additional modifiers as part of the description.

7. Pathology and Laboratory Guidelines
Tables
Table of Drugs and the Appropriate Qualitative Screening, Confirmatory, and Quantitative Codes
Molecular Pathology Table
Unlisted Service or Procedures
Check Category III codes before using unlisted procedure code
“If a Category III code is available, this code must be reported instead of a Category I unlisted code.”
Please turn to the Guidelines and the codes for Laboratory and pathology in your CPT book, and we’ll take a look at other types of information that might be useful to us.
UNLISTED SERVICE OR PROCEDURE
When reporting a service, where there is no appropriate code, you want to remember that there are Category III codes found at the end of the Medicine section, right after the Category II codes. Category III codes include new and emerging technology. Before deciding that a specific lab service is unlisted, you want to make sure that you’ve checked the entire Pathology and Laboratory section of the CPT® book, and you should also look in the Category III listings to make sure there’s no temporary code listed for that procedure. If there isn’t, then you can use one of the unlisted service codes listed in the Guidelines section. The unlisted codes are specific to various subsections of the Pathology and Laboratory section of the CPT® book.

8. Unlisted Service or Procedure
Special report
Description of:
Nature
Extent
Need for procedure
Describe:
Time
Effort
Supplies
Skills needed
Additional information about patient
When you use an unlisted procedure code or one of the new technology codes, sometimes it is required that you enclose a special report. The report should include an adequate definition or description of the nature, extent, and need for the procedure. It also should provide information about the time, effort and equipment necessary to provide the service. Additional information that may be helpful to the carrier include information about the patient, such as the complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures performed, concurrent problems, and planned follow-up care. The information is needed so the payer has a clear understanding of what the procedure is and what was required to perform it.

9. Organ or Disease-Oriented Panels
Group of tests commonly ordered together
All tests in the panel must be performed
Additional tests can be coded also
Some panels are included in other panels and should not be coded separately
Be on the look-out for “or” “and”
Let’s start looking at the actual subsections and some of the subheadings in the CPT® section on pathology and lab. This section begins with organ or disease-oriented panels. Often physicians will order a certain group of tests to determine whether a patient has a certain illness or to rule one out. The group of tests is called a panel.
CPT® has grouped tests that are ordinarily or commonly done together, assigned the group a specific code, and called the group a panel. This makes it easier for physicians who, consequently, don’t need to list every test they are ordering for a specific patient. This doesn’t mean that physicians have to order their lab work this way. The panels are designed to make it easier for them, but are not intended to tell them how to practice medicine. The individual tests that make up the panel are listed with their individual code so that you know exactly what tests are represented by the panel code. If one of the tests listed for a specific panel is not ordered, you cannot use the panel code. All the listed tests must be performed to use the panel code. The other thing that can happen is that in addition to everything listed in the panel code, the physician may order one or two additional tests. In this case, the coder uses the panel code and then lists the code for each additional test, not included in the panel, separately.

10. Organ or Disease-Oriented Panels
80047 Basic Metabolic Panel (Calcium, ionized)
80048 Basic metabolic panel (Calcium, total)
80053 Comprehensive metabolic panel
You will want to read through these panels carefully and note that some of the panel codes include a parenthetical statement at the end. These parenthetical statements tell you to not use a particular panel code along with another code. For example, don’t use the basic metabolic panel codes along with the comprehensive metabolic panel. If you look at the list of codes under each panel, you’ll find many of the same labs are repeated. You wouldn’t want to use both panel codes because you’d be double billing for some of the labs. In my CPT® book I have drawn an arrow from to 80053, because the note says not to use these two together. I’ve also drawn an arrow from to This helps me remember that the two basic metabolic panel codes are combined with the one comprehensive metabolic panel. I suggest you go through all of the panel codes and look for notes that tell you what is included and what should not be billed with other panel codes.
Do not report in conjunction with 80053

11. Organ or Disease-Oriented Panels
80050 General Health Panel
Comprehensive metabolic panel (80053)
Blood count, complete (CBC), automated and automated differential WBC count (85025 or and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009)
Thyroid stimulating hormone (TSH) (84443)
Find the general health panel code, in your CPT® book. For this panel they give you a choice of two different blood counts. Notice the word “OR” and highlight it or circle it, because the code does not include both of those tests. Either one blood count OR the other blood count is included. The general health panel, 80050, actually includes three components. It includes the comprehensive metabolic panel (80053) and, in addition to that panel, it includes one of the blood counts and a thyroid (TSH) test. Take some time to look at the notes. Pay attention when the note says not to use a specific panel code with another specific code. Look at the listed tests and compare them. Say, “Why not?” Look at how they are different and how they are similar. If you did use them together, would you be double billing? Also take the time to look for the word OR. Is it this blood count OR the other?

12. Organ or Disease-Oriented Panels
80055 Obstetric Panel
Blood count, complete (CBC) automated and automated differential WBC count (85025 or and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009)
hepatitis B surface antigen (HBsAg) (87340)
Antibody, rubella (86762)
Syphilis test, non-treponemal antibody, qualitative (eg, VDRL, RPR, ART) (86592)
Antibody screen, RBC, each serum technique (86850)
Blood typing, serologic ABO (86900) AND
Blood typing, Rh(D)(86901)
If you look at the obstetric panel code, 80055, there are two blood typing tests at the bottom of the list that need to be included, the connecting word here is “AND”, not “OR.” It is very important that they capitalize these words so that you see the difference easily. With the obstetric panel you also have two blood counts connected by an OR. Either one blood count or the other blood count is included in the panel, but not both. When you go down the list to the blood typing, the panel includes both ABO and Rh blood typing. Be sure to notice those two things and highlight them in your book, so that you don’t make errors.

13. Definitions Qualitative - What is present
Quantitative - How much is present
Example: Alcohol
Is there any alcohol in the blood (qualitative)
Measure of blood alcohol level (quantitative)
Before we move onto the drug testing subsection, let’s talk about two terms that you’ll see used often throughout the Pathology and Laboratory section of the CPT® book. The two terms are qualitative and quantitative. Some of the lab tests are quantitative. In other words, the tests are telling you how much of the analyte (or substance) is present in the specimen they looked at. In other cases, the lab test is qualitative and the test results tell you only that a specific type of analyte is in the blood or specimen.
Take for example alcohol testing. You might test to see whether there is any alcohol in the blood—which would be qualitative. But if the test actually measured the blood alcohol level, the test is considered quantitative. So qualitative testing measures whether something is present in the blood or other specimen. Quantitative testing tells you exactly how much of the analyte is present. You will see these terms used often throughout the rest of this book and you should consider what you’re coding and determine whether you want a qualitative answer or if you want a quantitative answer.

14. Definitions Therapeutic Drug Essays Quantitative
Drugs given for therapeutic purposes
Can become toxic or too low for benefit
Examples:
Lithium
Coumadin
The next subsection is therapeutic drug assays. These tests are quantitative. The list is a list of drugs that are being given for therapeutic purposes; however, since levels of them could become toxic to a patient, they are closely monitored. For example, lithium is a drug that is used to treat patients, but if there is a high level of it in the blood, it is toxic to the patient. So physicians carefully monitor this. Sometimes, after a heart attack, a patient is prescribed Coumadin to take daily. As a result, the patient has to go in periodically and have Coumadin levels checked in their blood. If they get too high, the patient could actually bleed to death from just a simple little cut. Levels can also be too low and not provide the desired therapeutic result. Coumadin needs to be high enough to provide protection. Physicians routinely check these levels to make sure that the drug levels don’t become dangerously high or low in patients on therapeutic, long-term drug treatments.

15. Evocative Suppression Testing
Baseline and subsequent measurement
Supplies and drug billed separately
Physician attendance
Use Prolonged care codes
Prolonged infusion codes from Medicine section
The next section of CPT® codes are for evocative/suppression testing. Evocative/suppression testing is when they administer a drug or an analyte and then they observe the patient to see what their reaction is. Either they give the drug or analyte to cause a reaction—which is considered evocative testing—or they give the drug or analyte to measure whether it will suppress the action or production of a particulate analyte. Whatever the reason they’re studying the patient, they will administer something that is going to cause one of those two reactions and then they test the blood or the specimen to see the result.
We read in the Guidelines, “The following test panels involve the administration of evocative or suppressive agents, and the baseline and subsequent measurement of their effects on chemical constituents. These codes are to be used for the reporting of the laboratory component of the overall testing protocol.” For the supplies and drugs you should also consider using HCPCS Level II codes if that’s what your payers want you to use, instead of
Codes in the medicine section of CPT® under “Hydration” & “Therapeutic, Prophylactic, and Diagnostic Injections and Infusions” are also useful with these tests. The Guidelines go on to explain, “In the code descriptors where reference is made to a particular analyte (for example, Cortisol: x2), the ‘x 2’ refers to the number of times the test for that particular analyte is performed.” Therefore, when the code description specifies a particular analyte x 2, it indicates they’re going to be testing for that particular analyte twice during that particular lab test.
You might find it beneficial to read through this list and underline or highlight the analyte times whatever the number is next to it, so that this sticks out when you’re reading the codes.

16. Consultations Requested by attending physician Rendered by pathologist
Written report provided
Patient not present
Lab test
Specimen
Slide
The next section is consultations and these consultations pertain to clinical pathology. What’s different about these consultations is that the patient is not present. So a clinical pathology consultation, we read, “is a service, including a written report, rendered by the pathologist in response to requests from an attending physician in relation to a test result(s) requiring additional medical interpretive judgment. Reporting of the test result(s) without medical interpretive judgment is not considered a clinical pathology consultation.” The key here is that there must be a written report. The clinical pathologist is being asked to review a lab test, a lab specimen, or a tissue sample—whatever the situation might be—and render his clinical judgment in a written report.
Again, the patient is not present. This is strictly a clinical review of information or a tissue sample.

17. Urinalysis Read descriptors Commonly performed in provider offices
Check payer contracts
The next subsection is urinalysis. You should read carefully through these codes and choose the correct code for the analysis that you’re performing, or the level of testing that you’re doing. Urinalysis is commonly performed in a provider’s office as a CLIA waived test. You will need to check your payer contracts as many insurance carriers consider a urinalysis inclusive to office visits.

18. Molecular Pathology Analysis of genes
Code selection is typically based on the specific gene(s) being analyzed
Include all analytical services performed in the test
Tier 1 – gene-specific
Tier 2 – less common
Multianalyte Assays with Algorithmic Analyses (MAAAs)
The Molecular Pathology section lists procedures involving the analyses of genes. This exciting and developing area of medical testing promises clues to illnesses and possible future treatments. Code selection is typically based on the specific gene or genes being analyzed. The molecular pathology codes include all analytical services performed in the test. This section contains useful definitions at the beginning of the section. “Gene,” “mutations” and other very useful terms are defined and should be reviewed.
Tier 1 Molecular Pathology Procedures are gene-specific representing genomic procedures. This includes genetic tests for breast cancer (BRCA1 & BRCA2) and for cystic fibrosis among others.
Tier 2 Molecular Pathology Procedures report codes for procedures not listed in Tier 1 Molecular Pathology. These codes represent medically useful procedures generally performed less commonly than Tier 1 Molecular Pathology Procedures. These codes are very specific and are listed by level ranging from Level 1 to Level 9.
Multianalyte Assays with Algorithmic Analyses (or MAAAs) are procedures utilizing multiple results from assays of various types. This can include molecular pathology assays, fluorescent in situ hybridization assays and nonnucleic acid-based assays. The information from algorithmic analysis using the results of assays along with other patient information is performed. This is reported typically as a numeric score or scores or as a probability. More specific instructions and Guidelines regarding the use of MAAAs can be found at the beginning of this section.

19. Hematology and Coagulation
Test Blood Clotting
Blood test
CBC
WBC
Hematology and Coagulation tests are performed specifically to test blood clotting (how fast a patient’s blood clots). This subsection also looks at the various types of blood tests that can be performed, such as a complete blood count (or CBC) and a white blood count (or WBC).

20. Immunology Qualitative or semiqualitative 86602-86804
Used to detect antibodies to the listed infectious agents
Single-step method (eg, reagent strip) 86318
Multiple-step method
Code for each assay performed
In the next subsection is a list of codes and, again, tucked inside the list of codes, toward the end of the list, there are some specific instructions. You will find the notes after the syphilis test. Just follow alphabetically through this section until you get down to code 86592, which is a syphilis test, qualitative, and then the quantitative code, There you will find some additional notes.
The guideline says, “The following codes…are qualitative or semiquantitative immunoassays that are performed by multiple-step methods for the detection of antibodies to infectious agents. For immunoassays by a single step method … use code Procedures for the identification of antibodies should be coded as precisely as possible. For example, an antibody to a virus could be coded with increasing specificity for virus, family, genus, species, or type. In some cases, further precision may be added to codes by specifying the class of immunoglobulin being detected. When multiple tests are done to detect antibodies to organisms classified more precisely than the specificity allowed by available codes, it is appropriate to code each as a separate service.”

21. Example 1st test is run to check for any antibodies for enterovirus
Antibodies identified for coxsackie A and B species
2nd test is run to identify the specific antibodies for each species
Code would be used 3 times
For example, a test for antibody to an enterovirus is coded as Coxsackie viruses are enteroviruses, but there are no codes for the individual species of enterovirus. If assays are performed for antibodies to Coxsackie A and B species, each assay should be separately coded. Similarly, if multiple assays are performed for antibodies of different immunoglobulin classes, each assay should be coded separately. When a coding option exists for reporting IgM specific antibodies…the corresponding nonspecific code …may be reported for performance of either an antibody analysis not specific for a particular immunoglobulin class or for an IgG analysis.
The Guidelines are very specific in telling you how to use these codes. So, you want to take your time and be very familiar with these Guidelines and then look at the codes they apply to and make sure you understand how to code them correctly. Once again, I cannot encourage you enough to take the time to read through all these codes and all these analytes and immunoglobulins and identify how they are different from each other. Highlight those differences. Look at the notes in the parenthetical statements. How do they apply? What are they telling to you to use? Are the notes telling you how to combine the codes? Are they telling you not to combine them? So really, take the time after this lecture to go through and look at each of these and note the differences.

22. Microbiology Study of viruses, microorganisms, parasites and bacteria
Presumptive identification – by colony
Definitive identification – requires additional tests
Code for additional studies
Use modifier 59 for multiple specimens
Use modifier 91 for repeat test on same day
Microbiology is the study of bacteria. So if we read the Guidelines under microbiology, it tells us that this section, “Includes bacteriology, mycology, parasitology and virology.” In other words, it is the study of bacteria, fungi, parasites, and viruses.
The next paragraph of the Guidelines says, “Presumptive identification of microorganisms is defined as identification by colony morphology, growth on selective media, Gram stains, or up to three tests …Definitive identification of microorganisms is defined as an identification to the genus or species level that requires additional tests …” For example, cultures. How many times have you gone to the physician’s office and they’ve taken a urine specimen and then told you they would call you back in a couple of days because they need to see if something grows out. That would be a culture of the urine to see if any organisms grow.
The Guidelines go on to say, “If additional studies involve molecular probes, Nucleic acid sequencing, chromatography, or immunological techniques, these should be separately coded… in addition to definitive identification codes … For multiple specimen/sites use modifier 59. For repeat laboratory tests performed on the same day, use modifier 91.” Also use modifier 59 if you are going to be testing multiple specimens, or doing multiple cultures on the specimens. These are tests that are specifically looking for bacteria or parasites on the cultures. They can be specific to the type of specimen that is submitted, or to the type of microorganisms they’re looking for.

23. Anatomic Pathology Autopsy (also called Necropsy) Gross exam only
Gross and microscopic exam
Limited
Regional
Single organ
Forensic
Coroners
Moving on through this section of the CPT® book we come to anatomic pathology and postmortem exams, or what we know more commonly as autopsy or necropsy.
They are divided into four different categories. The first is gross exam only of the body, and additional situations listed below. Progressing to the next category the organs are also examined by making slides and using the microscope. The third category is a limited autopsy of a region or single organ. Perhaps the patient died of a heart attack and they want to examine just that organ. A forensic exam is done in the case of a homicide victim to gather evidence to present at a court of law. A coroner is called if there is a death from unnatural causes; and in some cases when the patient does not have an attending physician, the coroner signs the death certificate.

24. Cytopathology Study of cells for disease Obtained by several methods
Washing or brushing
Smears
Fine needle aspiration
Cytopathology is the study of disease changes within individual cells or cell types. Cells can be obtained by several methods, such as by washing or brushing a surface, and are then studied on a slide under a microscope. Cells also may be collected with a fine needle aspiration of fluid.

25. Cytogenetic Studies Study of cells for inherited disorders
Molecular pathology procedures
Tier 1
Tier 2
Cytogenetic Studies examine cells for inherited disorders. Testing is done on tissue, frozen cells, and chromosomes. Molecular pathology procedures are reported using either the appropriate Tier 1, Tier 2 or the unlisted molecular pathology procedure code,

26. Surgical Pathology Specimen – tissue sample
Has to be separately identifiable
Divided into levels of progressive complexity
Level I – gross examination only
Level II-VI gross and microscopic exam
Additional codes for special stains
The last subsection we’re going to be looking at in the Pathology and Laboratory section of the CPT® book is surgical pathology. A specimen is a tissue sample that is submitted for separate examination and pathologic diagnosis. Each specimen that is to be evaluated has to be identified separately. Sometime several specimens are obtained during a procedure and sent to pathology in separate containers. Other times they may all be placed in one container. If they are in all in one container, that is considered one specimen unless each specimen one in the container can be separately identified. To do this, the physician will use ink or suture to label and identify each one separately.
These codes are divided into levels—levels I through level VI, and each level contains a different level of specimen or level of diseased tissue. When surgery is performed and tissue is removed or an organ is removed; or when a biopsy is performed and a lesion is excised; or a piece of a tissue is excised and sent for pathology studies; this is the section of CPT® you’re going to code from.
You use one of these codes for each specimen that you receive. If you receive multiple cysts, then you use the appropriate code for each cyst received as a specimen.
When a specimen is sent to pathology or sent to the pathologist, it is inspected. The first level, or Level I, is doing a gross exam only. The pathologist picks up the specimen and looks at it with his/her eyes and thinks, “Oh, yes. That is a liver. Or yes, that is an eyeball. Or, that is an amputated finger.” All they are doing is it looking at it with manual vision, and that’s considered a gross examination.
When you move into the next level, level II, the physician is doing not just the gross exam, but is also looking at tissue, blood, cells, or other specimens (whatever has been sent) with the microscope.

27. Surgical Pathology 88302 – Level II Skin, plastic repair
88304 – Level III
Skin – cyst/tag/debridement
88305 – Level IV
Skin, other than cyst/tag/debridement/plastic repair
Let’s take a look. These codes are listed by the type of sample identified, and each level moves up in severity or complexity. To try to illustrate this and make it a little bit easier, let’s look at the word “skin.” Skin in level II is just from a plastic repair. So what they have received in the pathology lab is some skin tissue that was removed strictly for plastic repair. Maybe it’s part of a face lift.
The surgeon has sent the tissue to make sure that there is nothing to be concerned about—there’s no skin cancer or anything else abnormal growing. The surgeon is making sure that the sample is healthy skin. That skin from the plastic repair is coded as a level II pathology.
If we look for the word skin in level III, we come to “Skin – cyst/tag/debridement.” So the sample might be a cyst that was removed and sent to pathology; or a skin tag that was removed and sent to pathology; or perhaps it’s just skin tissue that has been cut away or debrided from a wound, an ulcer or something else and the sample has been sent to pathology for study.
When we look at the word skin under level IV, we find that here skin is described as “other than cyst/tag/debridement/plastic repair.” So if skin is sent to pathology and it is not a cyst, tag, debridement, or plastic repair and it is from some other source, that specimen is coded using level IV. Perhaps it is a lesion that was on the skin or some other type of specimen and sent to be examined. Depending on what type of skin tissue being examined or the severity of the disease of the tissue, the code is going to move up or down in the levels.

28. Surgical Pathology 88304 – Level III Soft Tissue, debridement
Soft Tissue, lipoma
88305 – Level IV
Soft tissue, other than tumor/mass/lipoma/debridement
88307 – Level V
Soft tissue mass (except lipoma) – biopsy/simple excision
88309 – Level VI
Soft tissue tumor, extensive resection
Let’s look at another one for soft tissue. Soft tissue starts at level III and here it is described as soft tissue, debridement. The specimen is soft tissue debrided from a wound or other location. There is also a listing for soft tissue, lipoma, which is a group of fatty cells.
Under level IV we can look for soft tissue and now soft tissue is described as “other than tumor/mass/lipoma/debridement.” As long as the soft tissue that was removed is not one of those things listed, you code the specimen at this level.
If we move up to the next level (level V) and look for soft tissue we find now that it is described as, “Soft tissue mass (except lipoma) – biopsy/simple excision.” Moving on to level VI, we see soft tissue described as a soft tissue tumor with extensive resection.
I hope you can see how it is important to identify what type of sample you’re looking at, how severe it might be, or how progressive the disease is, so that you can categorize it at the right level. You always want to make sure that you put it into the proper category and not code it at a level higher than what it actually is. Nor do you want to code it at a lower level.
Following these Surgical Pathology level codes are codes for identifying special stains and testing that also can be done.

29. Pathology Consultation
Four types of consultations:
Report on prepared slides
Report on tissue requiring prep of slides
Review records and specimen
Consultation during surgery
Frozen sections
Cytology examination
In addition, there are Pathology Consultation codes where the opinion of the pathologist is requested by the attending physician. In the first type of consultation the pathologist is reviewing slides that have already been prepared and possibly already reported on by another pathologist. In the second consult the pathologist is sent a sample, a slide is prepared and analysis performed. The third type of consult includes the specimen analysis, as well as review of the patient’s medical records.
Sometimes during a surgical procedure, a pathologist will be asked to review the tissue while that patient is still in surgery so that the surgeon can determine if he needs to proceed with a procedure. For instance if a patient has a lump removed from her breast, the surgeon may want to wait for confirmation that it is benign or malignant. If the frozen section indicates that the tissue is malignant the surgeon may continue with a mastectomy or lumpectomy. If the specimen appears benign, the biopsy may be all that is performed.

30. In Vivo
Photometry
Non invasive test using visible and near infrared optical bands pressed to the skin
Measures bilirubin (neonates)
Hemoglobin, carboxyhemoglobin, and methemoglobin
The next subsections are transcutaneous procedures. These procedures use specialized visible and near infrared optical bands for measuring bilirubin, hemoglobin, carboxyhemoglobin, and methemoglobin through the patient’s skin. Transcutaneous means “through the skin.”
Other procedures is the subcategory for procedures that are performed in a laboratory but do not fit into any of the other categories.

31. Reproductive Medicine
In Vitro
Cryopreservation, storage and thawing of embryos
Sperm analysis
In the section for reproductive medicine procedures you will find the in vitro codes as well as the cryopreservation, storage and thawing of embryos. In addition, the physician will order tests on sperm for evaluation.

32. Closing Take the time to read through this section.
Highlight, circle, underline key words
Read parenthetical statements.
Read all notes
That’s the end of the CPT® section for pathology and laboratory. I cannot stress enough the importance of you pausing now before you proceed with the rest of your lesson and go through this entire Pathology and Laboratory section of your CPT® book. Read each and every code. Look at them and identify the differences. Highlight them, circle them, and underline them. Mark the codes in some way that will draw your eye to what the differences are. Read all the parenthetical statements. Often the parenthetical statements contain vital information that instructs you what codes to use with the one that you’re looking at, or what not to use.
Read all the notes you find before any codes. They usually contain very important information on how those codes are supposed to be used and what codes you might want to use in addition to them.
This concludes our lecture on the Pathology and Laboratory section of the CPT® codebook. Thank you for your time, and good luck with the rest of your lesson.

33. The End