Management & Compliance for Large/Academic Pathology Practices
Part 12 -
CAP Billing and CPT Coding Guidelines
Black-Schaffer & Johnson
CAP Billing and CPT Coding Guidelines
College of American Pathologists. CPT™ Coding Resource Center
[http://www.cap.org/apps/cap.portal?_nfpb=true&_pageLabel=cpt_coding_page] ; Cracking the Code
[Coding and Reimbursement Article Archive]
College of American Pathologists. Compliance Guidelines for Pathologists. Northfield , IL : CAP:
Released December 1998; Reviewed August 31, 2005
College of American Pathologists. Professional Relations Manual, Twelfth Edition. Northfield , IL :
CAP: 2003; Updated March 22, 2005
Teaching pathologist - criteria for billing
For any teaching service that is provided by a pathology trainee and for which
professional payment is sought, a teaching pathologist will supervise the trainee involved in the service
according to the following requirements:
(The pathology practice is not responsible for "moonlighting" activities.)
- A teaching pathologist will examine the specimen examined by the trainee and review the interpretation
of the trainee.
- The pathology report will state that the specimen has been examined and the interpretation is agreed
with or edited by the teaching pathologist.
- A teaching pathologist will be present for the key portion of any service provided by the pathology
trainee as part of the pathology training program, and will document that attendance.
Common scenarios and how to bill -- AP
No specified coding for a specimen
A specimen is received for which there is no specific coding information publicly available from
recognized coding authorities. What should the pathologist do?
It should be the responsibility of the pathologist involved in the case to assign the code that most
closely reflects the work involved when compared to other specimens assigned that code.
The pathologist should make a good faith effort accurately to code the services provided based on
related coding information available to him or her.
A gastric biopsy specimen consisting of only scant superficial fragments of gastric epithelium is
received. It is adequate for microscopic examination, but too scanty to exclude a disease process, and
additional sampling may be indicated. Can this be billed?
Yes. If the specimen is examined microscopically and reported, the service can be billed as a 88305.
A specimen container labeled "skin of nose" is received. No tissue is present in the container. Can
this be billed?
No. In this case, no specimen can be evaluated, and no charge should be made for an evaluation.
Question Three endoscopic biopsies from a colonoscopy are submitted in a single
container identified in the aggregate as colonic biopsies.
Answer These are all a single 88305.
Question Three endoscopic biopsies from a colonoscopy are each submitted in separate
containers identified as to origin (hepatic flexure; descending colon; rectum).
Answer Each of these three is a specimen that should be separately billed as a
Example A hysterectomy is performed for leiomyomas. The uterus containing leiomyomas
is submitted in one container; the right tube and ovary is separately identified in a second container;
the left tube and ovary is separately identified in a third container. A fourth container contains the
Billing The uterus and the right and left tubes and ovaries constitute a single
specimen, even though they are separately identified and submitted in separate containers. The
physician's work related to the uterus, tubes, and ovaries is coded as 88307. The vermiform appendix
does constitute a separate specimen and the physician effort related to this specimen is coded as 88302.
Example Two separate skin lesions are submitted in a single container; one is
separately identified by accompanying information which indicates "skin biopsy without suture from left
cheek; skin biopsy with suture from right cheek."
Billing Each of these two is a specimen that should be separately billed as a
When a pathology consultation on a single specimen during surgery does not involve microscopic
examination of tissue, the service is coded as one unit of 88329.
When a frozen section or sections from one block of tissue from a single specimen is examined
microscopically, the service is coded as one unit of 88331.
When a frozen section or sections from more than one block of tissue from a single specimen is
examined microscopically, the service is coded as one unit of 88331 and an additional unit of 88332 for
each block other than the first.
Two separately identified basal cell carcinomas from the face are submitted to the frozen section lab
for confirmation of diagnosis and evaluation of margins; the first requires one frozen section; the
second requires two frozen sections.
Each of the two is a separate 88305; the first is also a 88331; the second is also a 88331 and a
A laryngectomy specimen is sent to the frozen section laboratory intraoperatively for immediate
evaluation of margins. The pathologist examines the specimen and selects portions of the margins
resulting in four blocks of which frozen sections are examined microscopically.
The specimen is a code 88309; also bill for one unit of code 88331 and three units of code 88332.
Example: In the course of a radical prostatectomy, obturator lymph node resections from the
right and left sides are each submitted as separate specimens for immediate evaluation for metastatic
disease. The pathologist examines each of these specimens and selects portions of lymph nodes resulting
in two blocks from the right side lymph nodes and three blocks from the left side lymph nodes of which
frozen sections are examined microscopically.
Billing: Each regional lymph node resection specimen is coded as an 88307; the frozen section
services are also coded as one unit of 88331 and one unit of 88332 for the right side specimen and one
unit of 88331 and two units of 88332 for the left sided specimen, for a total of two units of 88307, two
units of 88331, and three units of 88332.
Coding for lymph node examinations is a common problem. When the CPT designation specifically
includes the lymph nodes (e.g. 88309, mastectomy or laryngectomy with regional lymph nodes) or when the
lymph nodes are ordinarily attached to the specimen (e.g. a lymph node adjacent to the neck of the gall
bladder with a cholecystectomy  or colectomy for neoplasm with mesenteric lymph nodes ),
examination of the lymph nodes is not to be coded separately. A periaortic lymph node is not ordinarily
removed with the colon or gall bladder and, if submitted, would be coded separately.
When multiple regional lymph node resections are dissected, each is examined separately to establish
the presence and extent of metastases and each dissection is reported separately. A radical prostate
resection does not include regional lymph nodes and each regional lymph node dissection would be reported
separately in addition to 88309. A sentinel lymph node biopsy is not a component of a regional lymph
node dissection, and the work in evaluating the sentinel lymph node is a distinct service. When a
sentinel lymph node biopsy is accompanied by a lymph node dissection, both services are coded separately.
The uniform CPT coding system for surgical pathology specimens published in Physicians Current
Procedural Terminology in 1992 includes regional lymph node dissection as a Level V (88307) service.
However, several Level VI (88309) specimens include regional lymph node dissection. "Breast,
Mastectomy--with Regional Lymph Nodes" and "Larynx, Partial/Total Resection--with Regional Lymph Nodes"
always are coded as a single service with 88309.
There are other Level VI (88309) services where lymph nodes also may be considered part of the Level
VI service, and where regional lymph nodes should not be coded separately.
Regional mesenteric lymph nodes removed with a colon resection are a part of that specimen; extended
lymph nodes from the periaortic region submitted separately, however, would be coded as 88307 in addition
to the 88309 for the colon resection.
Lymph nodes which accompany many radical resections but are not an integral part of the specimen
generally are coded separately. Such resections would include radical prostatectomy, hysterectomy and/or
salpingo-oophorectomy, orchiectomy, vulvectomy, partial or complete urinary cystectomy, glossectomy,
tonsillectomy, or bone resection. It should be the responsibility of the pathologist in each case to
make the coding assignment based on the general policy.
In coding for 88309 specimens, the general policy is that lymph node(s) are not to be separately coded
when the node(s) are part of the resected 88309 specimen. That is, if the node(s) are attached to the
primary specimen, they would not be coded separately. However, if the node(s) are a separate specimen,
they would be coded as 88307.
Pericolonic tissue containing lymph nodes that are attached to the colon would not be separately coded
for lymph nodes. However, retroperitoneal tissue submitted with a small intestine resection for tumor
would be coded separately as 88307. Likewise, any lymph nodes submitted with an esophagus resection or
extremity disarticulation specimen that are not attached to the primary specimen would be coded
In general, when lymph nodes are an integral part of a resection specimen, they are not coded
separately. For example regional mesenteric lymph nodes removed with a colon resection are a part of
that specimen. However, if extended lymph nodes from the periaortic region were submitted separately,
these would be coded as 88307 in addition to 88309 for the bowel resection.
In contrast, lymph nodes that may separately accompany many radical resections but are not an integral
part of the specimen generally are coded separately. Such resections would include radical
prostatectomy, hysterectomy, and/or salpingo-oophorectomy, orchiectomy, vulvectomy, partial or complete
urinary cystectomy, glossectomy, tonsillectomy, or bone resection. It should be the responsibility of
pathologists familiar with presentation of the specimen in each case to make the coding assignment based
on the general policy.
Fine-needle aspirations and core biopsies
Fine-needle aspirations are coded with procedure code 10021 or 10022 and evaluation codes 88172 and
Only one physician should code for each aspiration (CPT code 10021 or 10022); assistance by another
physician is not separately codeable.
The codes for immediate cytohistologic study to determine adequacy (88172) and definitive
interpretation (88173) also are to be reported per aspirate requiring separate evaluation as indicated by
the CPT wording.
For example, a pathologist examines an aspirate of a lung mass performed by a radiologist under
radiographic guidance and identifies only benign pulmonary elements that would not explain the mass. A
second aspirate is performed and the pathologist determines that this aspirate is diagnostic. The
assessment of each aspirate is reported as 88172. A pathologist aspirates two areas of the thyroid in a
patient with a diffusely enlarged gland and a large lower pole mass. Each aspiration would be coded as
10021 and each interpretation as 88173.
The 88172 code should not be used to report the assistance of a technologist during FNA -- 88172 is a
physician service code. Code 88173 should be used to report all FNA definitive interpretations, whether
a direct smear or a liquid-based slide preparation method is used.
Uterus, tubes, and ovaries
The codes for the uterus indicate they are "with or without tubes and ovaries." The descriptors for
ovary say they apply "with or without tubes." This direction is intended to indicate that when the tubes
and ovaries are removed incidentally to hysterectomy, or a tube is removed incidentally to ovarian
resection, physician work is not increased significantly and only a single code is used, even if the
surgeon places the organs in different containers. Thus, when a hysterectomy is performed for
leiomyomata and the surgeon places tubes and ovaries with only incidental findings in separate
containers, 88307 is reported once.
However, CPT treats ovaries and tubes as specimens coded separately from the uterus (Ovary, Non
neoplastic 88305; Ovary, Neoplastic 88307; Fallopian Tube, Biopsy 88305) when separate evaluation is
required and it is appropriate to code for evaluation of these organs. For example, when an ovary is
removed because of a neoplasm and the uterus is also resected, the ovary is the primary specimen.
Examination of the uterus is not included in the descriptor for evaluation of the ovarian neoplasm.
Therefore, the separate evaluation of the uterus is coded based on the work involved (88307 for non
neoplasm or leiomyoma(s) or 88309 for neoplasm). An appendectomy done at the same time would be coded as
88302 for an incidental removal, 88304 for an abnormal appendix.
Although diagnosis does not affect coding of many services, it is important for some specimens,
including these gynecologic evaluations, where CPT reflects differences in work examining neoplastic
versus non-neoplastic conditions. Coding is based on the extent of the required evaluation considering
both pathologic findings and clinical data. For example, a uterus with an endometrial carcinoma is coded
as 88309 even though the clinical diagnosis preoperatively was leiomyoma. A uterus removed because of a
history of carcinoma in situ is coded as an evaluation for neoplasm even if no residual neoplasm is
Cervical loop electrical excisions (LEEPs) are sometimes submitted as separate specimens that are
identified separately for orientation. The ectocervical portion of the LEEP excision should be coded
like a cervical conization (88307). If it is submitted as separate specimens, then each should be coded
as 88307 or 88305, depending on the work involved. Likewise, a separate endocervical specimen removed by
LEEP should be coded as 88305 or 88307, depending on the work involved. Small endocervical samples are
comparable to an endocervical biopsy or endocervical curettage (ECC) and 88305 is the appropriate code.
A larger endocervical LEEP is comparable to a cervical conization and should be coded 88307.
Twin third-trimester placentas are subject to the same definition of specimen rules as other cases.
If neither placenta is identified, there is one specimen and it should be coded as a single 88307. If
one of the placentas is identified (for example, by a clamp on the cord), then there are two specimens
and two 88307s should be reported.
Post-mortem examination of a stillborn fetus should be coded as an autopsy service or as a surgical
pathology service depending on the state and local laws governing fetal viability.
If the fetus is considered viable, an autopsy code should be used (88014, 88016, or 88029).
If the fetus is considered non-viable, it should be handled as a surgical specimen derived from the
mother and the 88309 code should be used.
Complex surgical pathology specimens - multiple organs and radical
In CPT, the specimen is the unit of coding for primary surgical pathology services 88300 to 88309.
The specimen is defined as "tissue or tissues that is (are) submitted for individual and separate
attention, requiring individual examination and pathologic diagnosis." The intent of this direction is
to treat tissues normally removed together as a single unit of service.
One should not code separately for the short segment of terminal ileum or the appendix that is part of
a right colectomy for a colon carcinoma. However, it would be appropriate to code for a separate
specimen when a segment of small bowel is submitted for evaluation of a lesion, such as ischemic bowel
disease (88307) and the surgeon finds and submits a separate segment of sigmoid colon with diverticulitis
(88307) or carcinoma (88309).
Separate codes also are appropriate when other organs that are not ordinarily part of a specimen
described in CPT are submitted and evaluated. A kidney, for example, is coded 88307; when the adrenal
gland, an unlisted specimen, is submitted with the kidney, it must also be examined and should be
assigned a code appropriate for the work involved, rather than 88307, adrenal resection.
When multiple organs are attached to one another or submitted in the same container, they should each
be coded appropriately. Radical cystoprostatectomy is an example. The prostate and bladder may be, but
are not ordinarily, removed together. These organs may be removed because of independent disease
processes or because disease extended from one organ to another.
If the bladder is removed for urothelial carcinoma and the prostate for prostatic adenocarcinoma, each
examination is coded 88309. If the prostate is removed because urothelial dysplasia extended into the
urethra and examination of the prostate was more limited than for a radical prostate resection, it would
be more appropriate to use 88307 to describe the prostate.
Pelvic resections or exenteration may be even more complicated to evaluate and code. A resection for
advanced rectal carcinoma, for example, could involve removing the bladder and internal genital organs.
These could be submitted as an en bloc resection or in separate containers.
The rectum would be coded as 88309 and each of the other organs that constitute a separate specimen
defined in CPT would usually be coded as 88307. If there were a distinct synchronous neoplasm, such as
carcinoma of the cervix, this would warrant use of 88309 for the uterus, tubes, and ovaries included in
Common scenarios and how to bill -- CP
Clinical laboratory services
Medical visits and consultation codes in the 90000 series may be used by pathologists to report
patient examination and evaluation services, such as in the emergency department, in the transfusion
medicine center, in the outpatient clinic, or at the bedside in the hospital.
Hematology and immunology codes in the 85000 and 86000 series may be used to report pathologist
services in peripheral blood smear interpretation and bone marrow aspiration and interpretation, and
blood bank physician services.
Consultation codes 80500 and 80502 may be used for clinical pathology consultations when requested by
an attending physician.
Physician hematology services include microscopic evaluation of bone marrow aspirations and biopsies.
It also includes those limited numbers of peripheral blood smears which need to be referred to a
physician to evaluate the nature of an apparent abnormality identified by the technologist. A
professional component payment is made for those services furnished to a hospital inpatient by a hospital
physician or an independent laboratory. The codes for these services are 85060, 85095, 85097, and 85102.
A pathologist receives a blood smear on an inpatient which needs to be referred to a physician for
microscopic evaluation of an apparent abnormality identified by a technologist. The pathologist
interprets the smear and issues a written report.
The pathologist should bill for this service using code 85060.
Additional billable physician hematology services include: bone marrow aspiration (85095); bone
marrow smear, interpretation only, with or without differential (85097); bone marrow biopsy (85102).
Blood banking services
Blood banking services of hematologists and pathologists are paid under the physician fee schedule
when analyses are performed on donor and/or patient blood to determine compatible donor units for
transfusion where crossmatching is difficult, or where contamination with transmissible disease of donor
is suspected. The blood banking codes are 86077, 86078, and 86079.
A pathologist investigates a case and interprets the findings where crossmatching is difficult to
determine compatible donor units for transfusion, or where contamination with transmissible disease of
donor is suspected. This is followed up with a written report.
The pathologist would bill for these services: for difficult crossmatch or irregular antibodies
evaluation, code 86077; for investigation of transfusion reaction with suspicion of transmissible
disease, code 86078; for authorization to deviate from standard blood banking procedures, code 86079.
Billing for a clinical consultation is appropriate under the physician fee schedule (codes 80500 and
80502) provided the following four criteria are met:
In any case, if the information could ordinarily be furnished by a nonphysician laboratory specialist,
the service of the pathologist is not a consultation payable under the physician fee schedule.
- The service is requested by the patient's attending physician;
- it relates to a test result that lies outside the clinically significant normal or expected range in
light of the condition of the patient;
- it results in a written narrative report included in the patient's medical record; and
- it requires the exercise of medical judgment by the consultant pathologist.
Routine conversations a pathologist has with attending physicians about test orders or results are not
consultations unless all four requirements are met.
A pathologist telephones a surgeon about a patient's suitability for surgery based on the results of
clinical laboratory tests. During the course of their conversation, the surgeon asks the pathologist to
review the patient's history and medical record and recommend whether the patient is a candidate for
surgery. The pathologist follows up his or her oral advice with a written report and the surgeon notes
in the patient's medical record that he or she requested a consultation.
This is a consultation payable under the physician fee schedule.
A pathologist contacts an attending physician to report test results and to suggest additional
testing. The attending physician takes notes on the recommendations and orders the tests indicated.
A professional charge can not be billed for this service since the attending physician did not request
a consultation to determine additional testing.
Clinical laboratory interpretations
Certain clinical laboratory interpretation services are payable under the physician fee schedule
provided that the following three criteria are met:
They relate to a test result that lies outside the clinically significant normal or expected range in
light of the condition of the patient.
They result in a written narrative report included in the patient's medical record.
They require the exercise of medical judgment by the pathologist.
These criteria are the same as three of the four criteria for clinical consultations; the difference
for these listed clinical laboratory interpretation services is that a hospital's standing order policy
can substitute for the individual request by the patient's attending physician required for a clinical
| CPT code ||Modifier ||Narrative|
|83020 ||26 ||Hemoglobin electrophoresis|
| 83912 ||26 ||Genetic examination|
| 84165 ||26 ||Protein e-phoresis, serum|
| 84166 ||26 ||Protein e-phoresis/urine/csf|
| 84181 ||26 ||Western blot test|
| 84182 ||26 ||Protein, western blot test|
| 85390 ||26 ||Fibrinolysins screen|
| 85576 ||26 ||Blood platelet aggregation|
| 86255 ||26 ||Fluorescent antibody, screen|
| 86256 ||26 ||Fluorescent antibody, titer|
| 86320 ||26 ||Serum immunoelectrophoresis|
| 86325 ||26 ||Other immunoelectrophoresis|
| 86327 ||26 ||Immunoelectrophoresis assay|
| 86334 ||26 ||Immunofix e-phoresis, serum|
| 86335 ||26 ||Immunfix e-phorsis/urine/csf|
| 87164 ||26 ||Dark field examination|
| 87207 ||26 ||Smear, special stain|
| 88371 ||26 ||Protein, western blot tissue|
| 88372 ||26 ||Protein analysis w/probe|
| 89060 ||26 ||Exam, synovial fluid crystals|
Clinical laboratory interpretations are professional component services only; if the information could
ordinarily be furnished by a nonphysician laboratory specialist, the service of the pathologist is not an
interpretation payable under the physician fee schedule.