1. PATHOLOGY / LABORATORY
CHAPTER 25
PATHOLOGY / LABORATORY 1

2. Types of Pathology and Laboratory
Subsections such as:
Organ or Disease-Oriented Panels
Drug Assay
Therapeutic Drug Assays
Evocative/Suppression Testing
Consultations (Clinical Pathology)
Urinalysis
Molecular Pathology
Chemistry
Hematology and Coagulation
Immunology
Transfusion Medicine
Microbiology
Anatomic Pathology
Cytopathology
Cytogenetic Studies
Surgical Pathology
Transcutaneous Procedures
Other Procedures
Reproductive Medicine Procedures
The Pathology and Laboratory section of the CPT manual is formatted according to types of tests performed. 2

3. Pathology and Laboratory
Figure 25.1
Codes for laboratory test only
Specimen collection coded separately
Example: Venous blood draw reported (Surgery section)
Medicare fee schedule each year identifies those lab tests associated with a physician component (modifier -26)
From Young AP, Proctor DB: Kinn's The Medical Assistant, ed 10, St. Louis, 2007, Saunders.
The services in the Pathology and Laboratory section include the laboratory tests only.
The collection of the specimen is coded separately from the analysis of the test.
Per the example: If a patient had a clinic lab technician withdraw blood by means of a venipuncture of the finger and the sample was analyzed in the lab:
Use code for venipuncture, in addition to a code to report the test performed on the blood.
Use G0001 for Medicare patients. 3

4. Facility Indicators
Allow additional tests without physician written order
Example:
Urinalysis positive for bacteria
Built-in indicator for culture
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.
Indicators imply that if a test is found positive, it is assumed that the physician wants more information on the condition.
If a routine urinalysis is performed, a culture is performed if the test is positive for bacteria. 4

5. Pathology/Laboratory Caution
Usually report second or subsequent tests without modifier -51, multiple procedures
Rather report times (x)
The only CPT modifiers used in this section are -90 and -91.
The CPT manual lists the drugs most commonly tested for, although the use of codes is not limited to the drugs listed.
The modifier -51 is not used with pathology or laboratory codes. Instead, each test is listed separately. 5

6. Organ or Disease-Oriented Panels (80047-80081)
Groups of tests often ordered together
Example:
Basic Metabolic Panel
General Health Panel
Electrolyte Panel
Codes in this subsection are grouped according to the usual laboratory work ordered by the physician for the diagnosis of, or screening for, various diseases or conditions.
Groups of tests may be performed together, depending on the situation or disease. 6

7. Rules of Panels
All tests must have been conducted and be medically necessary
Do not use modifier -52, Reduced Service
Additional tests, over those in panel, reported separately
If all tests in panel not performed
List each test separately
Do not use panel code
Problem oriented in scope
All tests in the panel description must have been conducted if the coder is to code for the panel.
If the entire panel is not completed, you would code each test separately. 7

8. Presumptive Drug Class Screening (80305-80307) (1 of 3)
Divided by methods
Three different method categories include:
Optical observation (80305)
Instrument assisted (80306)
Instrument chemical analyzers (80307)
Identifies presence or absence of drug
Drug screening is an analysis, which identifies the presence or absence of a drug.
Code this carefully. Understand that you can code the number of procedures performed, not the number of drugs being tested for.
Which code is reported if screening is performed visually? (80305) 8

9. Presumptive Drug Class Screening (80305-80307) (2 of 3)
Chromatography: procedure in which single or multiple drugs identified
Reports chromatography procedure(s)
Screening(s) is presumptive
Report 80307
The thin layer chromatography drug screen is presumptive for single or multiple drug class method, per date of service and reported with 9

10. Presumptive Drug Class Screening (80305-80307) (3 of 3)
Does not identify amount of drug present
Only presence or absence
The drug screening codes only tell if the drug is present, not the amount of the drug present. 10

11. Therapeutic Drug Assays (80150-80299)
Reports presence and amount (quantitative) or absence of a substance
Material examined can be from any source
Drugs listed by generic names
Example: Amitriptyline generic name for brand name Elavil
PDR a must for coding drug assays
Measures peaks (after drug given at intervals) and troughs (before drug given next dose)—used to monitor therapeutic drug for medication adjustment
Which codes are used for therapeutic drug assays? ( )
Drug assays test to detect a specific drug and to quantify the amount of that drug that is present.
What does quantitative information determine?
The presence of a drug
The exact amount present
A coder should have a drug reference (example: Mosby’s Drug Consult) handy to look up generic names of drugs that are listed by brand name in the medical documentation.
Drugs in the CPT manual are listed by generic, not brand, name. 11

12. Evocation/Suppression Testing (80400-80439) (1 of 2)
Measures stimulating (evocative—calling forth a response) or suppressing agents
Codes report only TC of service
Modifier -TC = Technical Component
This testing is performed to measure the effects of stimulating (evocative) or suppressing agents on chemical constituents.
Do you know:
Which codes are used to report supplies and/or drugs used in testing?
Which code is used if the physician administered the agent?
Which code is used if the test involved prolonged attendance by the physician? 12

13. Evocation/Suppression Testing (80400-80439) (2 of 2)
Additional services to report:
Supplies and/or drugs used in testing (99070 and/or HCPCS J codes)
E/M for physician monitoring of testing
If the physician supplies the agent, use code
If the physician administers the agent, refer to code range 90760, 90761,
If the test involves prolonged attendance by the physician, use appropriate E/M code. 13

14. Consultations (Clinical Pathology) (80500, 80502)
At request of physician
Additional information about specimen
Consultant prepares written report
Levels
Limited: Without review of medical record
Comprehensive: With review of medical record
At the request of a primary care physician, a clinical pathologist may be requested to perform a consultation to offer additional medical interpretation.
Consultations may be limited or comprehensive. 14

15. More Consultation Codes
Surgical Pathology,
Used when pathologist either
Reviews slides, material, or reports
Provides consultation during surgery
Reported on specimen, block, section, cytologic exam
Consultation codes are also found in the Surgical Pathology subsection.
What is included in the consultation codes? (Reviewing of slides, materials, or a report. The consultation is provided typically during surgery.) 15

16. Pathology Terminology
Specimen: Sample of tissue of suspect area
Block: Frozen piece of specimen
Section: Slice of frozen block
Example: Pathologist consults during surgical procedure
Examines one block = 88331
Examines each additional section of same block = 88332
Figure 25.2
Note that each specimen may be reported separately, but each slide from that specimen may not.
When one block is sectioned and examined, the service of examining the first section is reported with the use of
The second section, as well as subsequent sections of the same block, functions as an add-on code. But it is not marked as an add-on code.
Courtesy National Institute of Environmental Health Sciences—National Institutes of Health. 16

17. Urinalysis (81000-81099) (1 of 2) Tests on urine Method of test
Figure 25.3
Tests on urine
Method of test
e.g., tablet, reagent, or dipstick
Reason for test
e.g., pregnancy
Constituents being tested for
e.g., bilirubin, glucose
What are six things for the coder to remember when he or she is coding Urinalysis and Chemistry subsections? (1. The identification of specific tests; 2. Whether the test is automated or nonautomated; 3. The number of tests performed; 4. The identification of combination codes for similar types of tests; 5. Whether the results are qualitative or quantitative; and 6. The method of testing used)
From Proctor DB, Adams AP: Kinn's The Medical Assistant: An Applied Learning Approach, ed 12, St. Louis, 2014, Saunders. 17

18. Urinalysis (81000-81099) (2 of 2) Equipment used
Automated or nonautomated
With or without microscope
Number of tests performed
Codes for Urinalysis subsection? ( )
Urinalysis codes are for nonspecific tests done on urine.
What is the difference between an automated and nonautomated test? (Automated is done by a machine, whereas nonautomated is done manually.) 18

19. Chemistry ( ) (1 of 2)
Specific tests on any bodily substances
Urine
Blood
Most chemistry tests are quantitative (specific amount) unless specified qualitative
Breath
Feces
Codes for Chemistry subsection? ( )
Chemistry tests are performed on any bodily substance.
Codes are in alphabetical order in the CPT book.
What is the difference between quantitative and qualitative testing? (Qualitative is the presence of, while quantitative is how much is present.) 19

20. Chemistry ( ) (2 of 2)
Samples from different sources, reported separately
e.g., blood, feces
Samples taken at different times of day reported separately
Would a blood test and a feces test be reported separately? (Yes, different specimens)
If blood was drawn to check a potassium level at 8:00 AM and again at 2:00 PM, would both of these tests be billable? (Yes, because even though it is the same test performed twice, they were performed at different times of that day.) 20

21. Molecular Pathology (81105-81408, 81479)
are Tier 1 procedures that report molecular assay
More common gene specific procedures
Example, breast cancer gene–81162 (BRCA1 and BRCA2)
are Tier 2 procedures to report less commonly performed analyses
81479 reports unlisted molecular pathology procedures
Genes are described using the Human Genome Organization (HUGO) names and definitions.
Analyses of nucleic acid to detect variants in genes that may indicate disorders or neoplasia.
When a physician interpretation is required, modifier -26 is appended to the specific molecular pathology code.

22. Hematology and Coagulation (85002-85999)
Figure 25.4
Laboratory procedures on blood
Example
Complete blood count (CBC)
White blood cell count (WBC)
Codes divided based on method of
Blood draw
Test being conducted
What does the Hematology and Coagulation subsection report? (Various blood-drawing methods and tests)
The method used to perform the test is often what determines the code assignment.
What should coders do when there are many variations of just one test? (They should read the patient record and the code descriptions carefully before they assign a code.)
How are codes for blood coagulation tests divided? (According to the particular factor that is being tested)
From Abbott: CELL-DYN Emerald 22 Hematology Analyzer (website): Accessed August 8, 2018. 22

23. Immunology ( )
Identifying immune system conditions caused by antibodies and antigens
Example: Hepatitis C antibody screening
Tissue typing ( )
Basic assay, screening, typing
Immunology codes report tests that identify immune system conditions caused by antibodies and antigens.
Examples of such conditions? (Hypersensitivity, allergic reactions, immunity, alterations of body tissue) 23

24. Tissue Typing (86805-86849) Compatibility test on tissue
Match donor to recipient
Measure/monitor cytotoxic reactions

25. Transfusion Medicine (86850-86999)
Blood bank codes
Tests performed on blood or blood products
Do NOT identify supply of blood, but
Collection
Processing
Typing
The subsection deals with tests performed on blood or blood products.
These tests include screening for antibodies, Coombs testing, autologous blood collection and processing, blood typing, compatibility testing, and preparation of and treatment performed on blood and blood products.
Figure 25.5 25

26. Microbiology (87003-87999) Study of microorganisms
Identification of organism
Sensitivities of organism to antibiotics
Microbiology deals with the study of microorganisms and includes the following:
Bacteriology
Mycology
Parasitology
Virology
What is bacteriology? (Study of bacteria)
What is mycology? (Study of fungi)
What is parasitology? (Study of parasites)
What is virology? (Study of viruses)
From Mandell GL, Bennett JE, Dolin R: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, ed 7, Philadelphia, 2010, Churchill Livingstone. 26

27. Microbiology Caution
Figure 25.6
Many code descriptions similar to those in Immunology ( )
Difference is technique used
Courtesy United States Environmental Protection Agency.
Culture codes need to be read carefully because some codes are used only to detect the presence of an organism and others show additional sensitivity testing to determine which antibiotic would be best to use for treatment. 27

28. Anatomic Pathology (88000-88099)
Postmortem examinations
Autopsies
Reports only physician service
Codes divided on extent of exam and type of exam (gross versus gross and microscope)
Example:
Gross exam without central nervous system (88000)
Gross and microscopic without central nervous system (88020)
Postmortem exams:
Deal with examination of the body after death.
Autopsy codes are divided by gross exam only or gross and microscopic. These are further divided on what the autopsy consisted of.
For example: an autopsy with gross and microscopic exam, with brain and spinal cord (88027). 28

29. Cytopathology (88104-88199) Identify cellular changes
Common laboratory procedures
e.g., Pap smear
Codes divided on
Type of procedure
Technique used
Cytopathology deals with laboratory work performed to determine whether any cellular changes have occurred.
Most common code is the Pap smear. 29

30. Cytogenetic Studies (88230-88299)
Branch of genetics concerned with cellular abnormalities and pathologic conditions
Example: Chromosomes
Cytogenetic studies include tests that are performed for genetic and chromosomal studies.
Why may a test be performed from this subheading? (To rule out inheritance of a disorder) 30

31. Surgical Pathology (88300-88399) (1 of 3)
Evaluation of specimens to determine disease pathology
All tissue removed during procedures undergoes pathology evaluation
These codes are concerned with the evaluation of specimens to determine the pathology of disease processes.
Pathology testing is performed on all tissue removed from the body.
The codes include accessing them, examination of the specimen, and reporting of the findings.
The unit of service for these codes is the specimen. 31

32. Surgical Pathology (88300-88399) (2 of 3)
Operative report usually coded after pathology report received
Pathology reports usually coded with OR
The diagnosis for the operative procedure is taken from the pathology report if pathology was performed.
If a patient had a chronic cough and the operative report was billed as a chronic cough but later the pathology report comes back as pneumococcal pneumonia. The cough was just a symptom of the pneumonia, which is why you should always wait for the pathology report. 32

33. Surgical Pathology (88300-88399) (3 of 3)
Unit of measure ( ), specimen
Two anus tags, each examined, x 2
One anus tag examined in two different areas of tag, 88304
If two specimens from the same area are received and examined, each specimen is coded.
What is a specimen? (Tissue submitted for examination)
The number of specimens equals the number of units. 33

34. Types of Pathologic Examination
Microscopic: With microscope
Gross: Without microscope
88300, only gross exam code
Others gross and microscopic
Microscopic examination cannot be seen with the naked eye.
Gross examination is large enough to see without a microscope.
Courtesy of Cynmar Corporation, Carlinville, IL 34

35. Six Levels of Surgical Pathology (1 of 2)
Based on specimen examined
e.g., breast, prostate, lung
And reason for evaluation
e.g., radical procedure for suspected carcinoma
In assigning the correct code, the coder must identify the source of the specimen and the reason for the surgical procedure.
The higher the level of surgical pathology the more complex the examination. 35

36. Six Levels of Surgical Pathology (2 of 2)
Levels divided on complexity of examination
Examples:
88305: Colon, biopsy
88307: Colon, segmental resection, other than for tumor
88309: Colon, total resection
Surgical pathology is divided by the area of the body and the complexity of the procedure.
How many levels of Surgical Pathology are there? (Six) 36

37. The Gram stain. Red blood cells (RBC) and gram-positive cocci.
Levels
The Gram stain. Red blood cells (RBC) and gram-positive cocci.
Level I
Specimen can be diagnosed without microscopic examination
Level II
Gross and microscopic examination performed
Levels III, IV, V, and VI
Includes gross and microscopic examination and additional physician work (increasing difficulty)
Based upon method of or need for removal
Same anatomical site can be listed in each level
From McPherson RA, Pincus MR: Henry’s Clinical Diagnosis and Management by Laboratory Methods, ed 22, St. Louis, 2011, Saunders.
Knowing these different levels makes coding for surgical pathology easier.
Always look under the code in the CPT manual to find if the specimen and surgical procedure fall there. 37

38. Not Included In Codes
Additional service codes are not included in codes
Example: Special stains (88312)
Additional services reported separately
Which codes are used for additional services? ( )
Remember, additional services must be reported separately. 38

39. PATHOLOGY / LABORATORY
Conclusion CHAPTER 25
PATHOLOGY / LABORATORY 39