Slide 1CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
PATHOLOGY AND LABORATORY
PATHOLOGY AND LABORATORY
Slide 2CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Pathology & Laboratory Format(80048-89356)(80048-89356)
Pathology & Laboratory Format(80048-89356)(80048-89356)
Organ or Disease Panels
Drug Testing Therapeutic Drug
Assays Evocation/Suppression
Testing Consultation
(Clinical Pathology) Urinalysis Chemistry
Hematology and Coagulation
Immunology Transfusion Medicine Microbiology Infectious
Agent Detection Anatomic Pathology Cytopathology Cytogenetic Studies Surgical Pathology Transcutaneous Procedures Reproductive Medicine
Procedures
Slide 3CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Pathology & Laboratory FormatOrgan or Disease Oriented PanelsPathology & Laboratory Format
Organ or Disease Oriented Panels
The services in the Pathology & Laboratory section include laboratory teststests only. The collection of the specimenspecimen is coded separately from the analysis of the test.
Example:Example: If a patient had a technician in a clinic laboratory withdraw blood by means of a withdraw blood by means of a venipuncture of the arm, and the blood sample venipuncture of the arm, and the blood sample was then analyzed in the laboratory,was then analyzed in the laboratory, you would code 3641536415 for the venipuncture in addition to a code to report the test performed on the blood.
Slide 4CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Pathology & Laboratory SubsectionOrgan or Disease Oriented Panels
80047-80076
Pathology & Laboratory SubsectionOrgan or Disease Oriented Panels
80047-80076 Code in subsection are grouped according to the
usual laboratory work ordered by a physician for the diagnosis of or screening for various diseases or conditions.
ExamplesExamples Basic metabolic panel - 80048- 80048 General health panel - 80050- 80050 Electrolyte panel - 80051- 80051
Slide 5CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Rules of PanelsRules of Panels
All tests must have been conducted Do not use -52,-52, Reduced Service Additional tests, over those in panel, reported
separately If all tests in the panel are not donenot done::
• List each test separately
• Do not use panel code
Slide 6CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Pathology & Laboratory SubsectionOrgan or Disease Oriented Panels
80047-80076 PERFORMANCE EXERCISEPERFORMANCE EXERCISE
Pathology & Laboratory SubsectionOrgan or Disease Oriented Panels
80047-80076 PERFORMANCE EXERCISEPERFORMANCE EXERCISE
Hepatic function panel code.
80076
Lipid panel
80061
Slide 7CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Drug Testing (80100-80103)(80100-80103)Drug Testing (80100-80103)(80100-80103)
Laboratory Drug Test is done to Identify presence or absence of drug.
Testing that determines the presence or absence of a drug is qualitative.
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 8010280102 is used to describe this confirmation test.
Slide 8CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Drug Testing (80100-80103)(80100-80103)Drug Testing (80100-80103)(80100-80103)
Code from the Therapeutic Drug Assay & Therapeutic Drug Assay & Chemistry Chemistry subsection are used to further identify the exact amount of the drug that is present (quantitative)
EXAMPLE: EXAMPLE: A patient who has been on a medication for a long time might need to undergo testing to determine whether the drug leveldrug level is therapeutic.
Slide 9CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Drug Testing Drug Testing
Chromatography Chromatography procedure in which multiple drugs identified:
• Some machines identify all drugs present in one procedure
• Others require two procedures or more to identify two or more drugs
Slide 10CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Drug Testing Drug Testing
Code the number of procedures, not the number of drugs tested:
Examples Examples Two procedures to identify three drug = 80100 × 280100 × 2 One procedure to identify three drugs = 80100 80100
Slide 11CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Drug TestingDrug Testing
Does not identify amount of drug present• Only presence or absence (qualitative)(qualitative)
Report presence & amount (quantitative)(quantitative)• Therapeutic Drug Assays (80150-80299)
• Chemistry (82000-84999)
Slide 12CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Therapeutic Drug Assays (80150-80299)(80150-80299)Therapeutic Drug Assays (80150-80299)(80150-80299)
Material examined can be from any source Drugs listed by generic names
Example: amitriptyline (generic name for brand name Elavil)
• PDR is a must for coding drug testing
Slide 13CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Therapeutic Drug Assays (80150-80299)(80150-80299) PERFORMANCE EXERCISEPERFORMANCE EXERCISE
Therapeutic Drug Assays (80150-80299)(80150-80299) PERFORMANCE EXERCISEPERFORMANCE EXERCISE
Confirmation of cocaine (qualitative)
80102
Identify the amount of digoxin in the blood (quantitative)
80162
Slide 14CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Evocation/Suppression Testing (80400-80440)(80400-80440)Evocation/Suppression Testing (80400-80440)(80400-80440)
Measures stimulating (evocative) or suppressing agents
Codes report only TC (Technical Component) of service
Slide 15CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Evocation/Suppression Testing (80400-80440) (80400-80440)Evocation/Suppression Testing (80400-80440) (80400-80440)
Additional services to be reported• Supplies and/or drugs used in testing (99070(99070 or
HCPCS code)HCPCS code)
Physician-administered agent• Infusion or Injection code (90780 and 90781)(90780 and 90781)
E/M for physician monitoring of testing
Slide 16CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Consultation (Clinical Pathology) (80500-80502)(80500-80502)Consultation (Clinical Pathology) (80500-80502)(80500-80502)
There are two codes under this subsection reserved for clinical pathology consultation. clinical pathology consultation.
These consultations are based on whether the consultation is limitedlimited or comprehensivecomprehensive.• Limited: Done withoutwithout the pathologist review of
the patient’s medical record
• Comprehensive: Comprehensive: Done withwith review of medical record as part of the consultation service.
Slide 17CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
More Consultation CodesMore Consultation Codes
Pathology Consultations during surgery are provided to examine tissue removed from a patient during a surgical procedure.
If the pathologist did notnot use a microscope to examine the tissue, report code 88329.88329.
If a microscope was used to examine the tissue, report 8833188331 or 8833288332, depending on the number of samples number of samples that were examined
Slide 18CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Pathology TerminologyPathology Terminology A Specimen:A Specimen: Sample of tissue of suspect area A Block:A Block: Frozen piece of specimen A Section:A Section: Slice of frozen block
A pathologist prepares a specimen by cutting it cutting it into blocks and into blocks and taking sections from the blocks.taking sections from the blocks.• 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 on a slide or held by other means that allow the pathologist to view the tissue under a microscope.
Slide 19CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Pathology TerminologyPathology Terminology
Each Each specimenspecimen may be reported separately, may be reported separately, but each but each slideslide from that specimen may not. from that specimen may not.
Example:Example: Pathologist consults during surgical Pathologist consults during surgical procedure procedure
Examines Examines 1 block 1 block == 8833188331 Examines Examines 2nd2nd section of same block = section of same block = 8833288332
Slide 20CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Urinalysis (81000-81099)(81000-81099)Urinalysis (81000-81099)(81000-81099)
Non-specific Tests on Urine Method of test:
• Examples:Examples: Tablet, reagent, or dipstick
Reason for test:• Example: Example: Pregnancy
Constituents being tested:• Examples:Examples: Bilirubin, glucose
Slide 21CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
UrinalysisUrinalysis
Equipment used• Automated or nonautomated
Number of tests performed
Slide 22CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Chemistry (82000-84999)(82000-84999)Chemistry (82000-84999)(82000-84999)
Specific tests on any bodily substances• Urine
• Blood
• Breath
• Feces
• Sputum
Slide 23CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Chemistry Chemistry
Codes used mostly for qualitative (presence) screenings only
Four codes report quantitative (amount)
screenings (80100-80103) (80100-80103)
Slide 24CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
ChemistryChemistry
Samples from different sources reported separately
Examples: Blood, feces Samples taken different times of day reported
separately
Slide 25CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Urinalysis & Chemistry (80100-84999)(80100-84999) PERFORMANCE EXERCISEPERFORMANCE EXERCISE
Urinalysis & Chemistry (80100-84999)(80100-84999) PERFORMANCE EXERCISEPERFORMANCE EXERCISE
An automated urinalysis without microscopy.
81003
Uric acid, blood
84550
Slide 26CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Hematology & Coagulation (85002-85999)(85002-85999)Hematology & Coagulation (85002-85999)(85002-85999)
Laboratory procedures on bloodExamples
Complete blood count (CBC) (CBC) White blood cell count (WBC)
Codes divided based on:• Blood draw
• Test being conducted
Slide 27CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Hematology & Coagulation (85002-85999)(85002-85999) PERFORMANCE EXERCISEPERFORMANCE EXERCISE
Hematology & Coagulation (85002-85999)(85002-85999) PERFORMANCE EXERCISEPERFORMANCE EXERCISE
Blood count by automated hemogram (TBC, WBC, Hgb, Hct, and platelet count)
85027
Automated RBC
85041
Slide 28CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Immunology (86000-86849)(86000-86849)Immunology (86000-86849)(86000-86849)
Deal with identifying immune system conditions caused by antibodies & antigens
Example:Example: Hepatitis C antibody screening
PERFORMANCE EXERCISEPERFORMANCE EXERCISE ANA (antinuclear antibody) titer
86039
Slide 29CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Transfusion Medicine (86850-86999)(86850-86999)Transfusion Medicine (86850-86999)(86850-86999)
Blood Bank Codes Tests performed on blood or blood products Does NOT identify supply of blood, but
• Collection
• Processing
• Type
PERFORMANCE EXERCISEPERFORMANCE EXERCISE Irradiation of blood product, 3 units
86945 x3
Slide 30CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Microbiology (87001-87999)(87001-87999)Microbiology (87001-87999)(87001-87999)
Study of Microorganisms• Identification of organism
• Sensitivities of organism to antibiotics
Many code descriptions are similar to those in Immunology (86000-86849)(86000-86849)• The difference is the technique used
Slide 31CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Microbiology (87001-87999)(87001-87999)PERFORMANCE EXERCISEPERFORMANCE EXERCISEMicrobiology (87001-87999)(87001-87999)PERFORMANCE EXERCISEPERFORMANCE EXERCISE
Quantification of HIV-1, herpes, and Candida species.
1. 87536 – HIV-1, quanfification
2. 87530 – Herpes simplex
3. 87482 - Candida species
Bacterial culture of urine, quantitative with colony count.
87086
Slide 32CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Anatomic Pathology (88000-88099)(88000-88099)Anatomic Pathology (88000-88099)(88000-88099)
Postmortem Examinations • Autopsies
Reports only physician service Codes divided on extent of exam
Example: Example: With or without central nervous system
Slide 33CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Cytopathology (88104-88199)(88104-88199)Cytopathology (88104-88199)(88104-88199)
Identifies cellular changes Common laboratory procedures
Example:Example: Pap smear
Codes divided on• Type of procedure
• Technique used
Slide 34CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Cytogenetic Studies (88230-88299)(88230-88299)Cytogenetic Studies (88230-88299)(88230-88299)
Branch of genetics concerned with cellular abnormalities & pathologic conditions
Cytogenetic Studies Cytogenetic Studies include tests performed for genetic and chromosomal studies.
Slide 35CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Surgical Pathology (88300-88399)Surgical Pathology (88300-88399)
Evaluation of specimens to determine pathology of disease processes.
All tissue removed during procedures undergoes pathologic evaluation
Slide 36CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Surgical PathologySurgical Pathology
This subsection contains codes that are divided into six six levels levels based on the specimen examined and the level of work required by the pathologist
Level I Level I – code 8830088300 identify specimens that normally do not need to be viewed under a microscope for pathologic diagnosis.
Level II Level II – code 8830288302 deals with tissues that are usually considered normal tissue and have been removed, not because of the presence of disease or malignancy, but for reasons such as “fallopian tubes for the sterilization”.
Slide 37CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Surgical PathologySurgical Pathology
Level III - code 8830488304 is assigned for specimen with a low neoplastic probability of disease or malignancy.
Level IV Level IV – code 8830588305 carries a higher probability of malignancy or decision making for disease pathology.
Level V Level V - code 8830788307 classifies more complex pathology evaluation.
Level VI Level VI - code 88309 88309 includes examination of neoplastic tissue or very involved specimens.
Slide 38CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Surgical Pathology (88300-88399)(88300-88399)PERFORMANCE EXERCISEPERFORMANCE EXERCISESurgical Pathology (88300-88399)(88300-88399)PERFORMANCE EXERCISEPERFORMANCE EXERCISE
The specimen is a uterus, tubes, and ovarian. The procedures was an abdominal hysterectomy for ovarian cancer.
88309
The specimen is the prostate. The procedure was transurethral resection of the prostate.
88305
Slide 39CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Types of Pathologic ExaminationTypes of Pathologic Examination
Microscopic: With microscope
Gross: Without microscope• 8830088300,, Only gross exam code
• Others gross & microscopic
Slide 40CPT – Pathology & Laboratory Section – Medical Coding IIMessick Adult & Technology Center
Not Included in Codes 88300-8830988300-88309 Not Included in Codes 88300-8830988300-88309
Any special services necessary during specimen examination:
Example:Example: Special Stains
• Additional services reported separately (88311-88399)(88311-88399)