1. New Provider and Reappointment Training
Pathology Coding
March 2019

2. Course Objectives
Review basic principles of coding and documentation of pathology services
Review resident/fellow supervision and documentation requirements for Medicare, Medicaid and TRICARE

3. Coding and Documenting Pathology Services

4. Documentation for Cytopathology Services
The documentation should include (as applicable):
Clinical history
Specimen source
Type of specimen
Special stains, including positive or negative results
Preparation of additional slides
Preliminary results
Reference results of all additional studies
The diagnosis for each specimen
CPT © 2019

5. Documentation for Surgical Pathology Services
The documentation should include (as applicable):
Clinical history
Itemization of each specimen received and analyzed
Specimen source
Gross description
Microscopic description
Special stains, including positive or negative results
Reference results of all additional studies
Reference/results of all consults and frozen sections
The diagnosis for each specimen
CPT © 2019

6. Clinical Pathology Consultations
Clinical consultations are paid under the Medicare Physician Fee Schedule (MPFS) only if they:
a. Are requested by the patient’s attending physician;
b. Relate to a test result that lies outside the clinically significant normal or expected range in view of the condition of the patient;
c. Result in a written narrative report included in the patient’s medical record; and
d. Require the exercise of medical judgment by the consultant physician.
Routine conversations held between a laboratory director and an attending physician about test orders or results do not qualify as consultations unless all four requirements are met.

7. Clinical Pathology Consultations
CPT – Clinical pathology consultation; limited, without review of patient's history and medical records
CPT – Clinical pathology consultation; comprehensive, for a complex diagnostic problem, with review of patient's history and medical records
Reporting of a test result(s) without medical interpretive judgement is not considered a clinical pathology consultation.
CPT © 2019

8. Anatomic or Surgical Pathology Consultations
When pathologists refer cases to each other for second opinions on anatomic or surgical pathology tests, it is imperative to document appropriately.
The documentation should indicate whether the slides were prepared elsewhere (CPT 88321) or required preparation (CPT 88323).
If the consulting pathologist needs to review previous medical records and specimens in order to render an opinion, this must be explicitly noted in the documentation (CPT 88325).
Intraoperative pathology exam – When a pathologist is consulted during a surgery to render an opinion on the presence or absence of diseased or abnormal tissue provided (gross examination without concurrent microscopic examination), CPT may be used.
CPT © 2019

9. Modifiers That Impact Payment
Modifier 91 – Repeat Clinical Diagnostic Laboratory Test
In the course of treatment, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91.
This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required.
This modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing).
This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.

10. Diagnosis Coding Tests ordered due to signs and/or symptoms:
If the physician has confirmed a diagnosis based on results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis. The definitive diagnosis code should be sequenced before the symptom code.
If the diagnostic test did not provide a diagnosis or the diagnosis was normal, the interpreting physician should code the sign(s) and/or symptom(s) that prompted the treating physician to order the study.
Always code to the highest level of specificity possible.

11. Diagnosis Coding
Tests ordered without a definitive diagnosis or signs/symptoms:
If the results of the study are normal or non-diagnostic, and the referring physician records a diagnosis preceded by words that indicate uncertainty (e.g., probable, suspected, questionable, rule out, or working), then the interpreting physician should not code the referring diagnosis. Rather, the interpreting physician should report the sign(s) and/or symptom(s) that prompted the study.
On the occasion when the interpreting physician does not have diagnostic information as to the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient’s medical record if it is available. However, an attempt should be made to confirm any information obtained from the patient by contacting the referring physician.

12. Teaching Physician Guidelines

13. Medicare Teaching Physician Guidelines
Medicare pays for the interpretation of diagnostic tests if the interpretation is performed by or reviewed with a teaching physician.
If a resident prepares and signs the interpretation, the teaching physician must indicate that he or she has personally reviewed the specimen and the resident’s interpretation and either agrees with or edits the resident’s findings.
The resident should not document the participation of the teaching physician.
Co-signature of a resident's interpretation alone is not sufficient for billing Medicare.
Acceptable Attestation for Medicare:
“I have personally reviewed the specimen and the resident’s interpretation and agree with the findings as documented by the resident.

14. North Carolina Medicaid Requirements
The degree of supervision is the responsibility of the teaching physician and is based on the skill, level of training, and experience of the resident as well as the complexity and severity of the patient's condition.
Written documentation in the medical record for Medicaid patients must clearly designate the supervising physician and be signed by that physician.

15. TRICARE Teaching Physician Requirements
Documentation of supervision must be entered into the medical record by the supervising practitioner or reflected in the resident progress note or other appropriate entries in the medical record (e.g., procedure reports, consultations, discharge summaries)
Pathology reports must be verified by a supervising practitioner.
Co-signatures are required unless the Resident documents the name of the supervising practitioner with whom the case was discussed, a summary of the discussion, and a statement of the supervising practitioner’s oversight responsibility for the assessment, diagnosis, plan for evaluation, or treatment.
Acceptable Attestation for TRICARE:
“I have personally reviewed the specimen and the resident’s interpretation and agree with the findings as documented by the resident.
For the purposes of meeting TRICARE guidelines, UNC will use the same attestations for both Medicare and TRICARE regarding TP supervision.

16. Contact Us EMAIL AND WEBSITE ProComplianceUNCHC@unchealth.unc.edu
DIRECTOR
Robin Davis Shuping, RN, MHA, CPC | System Director,
Professional Compliance – UNC Health Care
Hedrick Building, Suite G050
211 Friday Center Drive
Chapel Hill, NC 27517
Ph (984) | Fax (984)
ASSOCIATE DIRECTOR
Laura Bushong, MSJ, CPC, CHC | Associate Director Professional Compliance – UNC Health Care
Hedrick Building, Suite G063
211 Friday Center Drive 
Ph (984) | Fax (984)