Q: We performed a complete blood cell count on an 83-year-old female hospital inpatient. The medical technologist noted some immature cells on the peripheral smear and sent it to the pathologist for interpretation. The pathologist reviewed the peripheral smear and issued a written interpretive report for the medical record. What CPT code should we use for this service?
A: Use CPT code 85060, Blood smear, peripheral, interpretation by physician with written report, for the service described.
Q: A physician requested, in writing, a consultation by the pathologist on the lab results for a 72-year-old male with an abnormal complete blood cell count. The pathologist reviewed the abnormal CBC, including a peripheral blood smear, and rendered a diagnosis of microcytic hypochromic anemia, most likely due to iron deficiency. The pathologist recommended initial followup testing, including reticulocyte count, serum iron, ferritin, and stool for occult blood. The pathologist rendered a written report of these findings for the medical record. What CPT code should we use for these services?
A: Use CPT code 80500, Clinical pathology consultation; limited, without review of patient's history and medical records. The code requires that the patient's physician request the consultation and document such in writing, the patient have an abnormal or unexpected lab result, the consultant make a medical judgment, and the consultation be written and incorporated into the medical record.
Frequently asked questions about CPT are published bimonthly. This section of CAP TODAY is a product of the CAP Economic Affairs Committee.
The codes and descriptions listed here are from Current Procedural Terminology, 4th ed., CPT 2008. CPT 2008 is copyrighted by the American Medical Association. To purchase CPT books, call the AMA at 800-621-8335.
For more information about CPT coding, visit the CPT Coding Resource Center on the CAP Web site.