Reprinted from December 2003 CAP
Q: Is it appropriate to bill for processing and staining specimens—for
example, CSF, bone marrow aspirate—when the slide yields non-diagnostic
results due to an inadequate specimen or insufficient numbers of cells?
A: If the specimen is absolutely devoid of cellular elements,
it should be designated as unsatisfactory or inadequate for examination,
and the pathologist should not charge for an evaluation. If the specimen
contains material that is reviewed for diagnostic findings and a report
is issued, then the pathologist can code and bill for the service, even
if the material is too scant to exclude a particular disease process.
Q: We processed an upper lobe posterior segment partial lobectomy
followed by an additional partial lobectomy from the same lobe of the
lung. Can these services be billed separately, or should they be reported
with one code?
A: A specimen is defined by CPT as “tissue or tissues submitted
for individual and separate attention, requiring individual examination
and pathologic diagnosis.” A segmental resection is coded as 88309. If
the partial lobectomy was submitted for separate evaluation, it would
be appropriate to code it as 88309. The second segment would be coded
as an additional unit of 88309. If the specimens are not separately identified
or distinctly identifiable, then it would be appropriate to report as
a single unit 88309.
Frequently asked questions about CPT are published bimonthly in “Capitol
Scan.” This addition to CAP TODAY is a product of the CAP Economic
The codes and descriptions listed here are from Current Procedural Terminology,
a copyrighted publication of the American Medical Association. To purchase
CPT books, call the AMA at (800) 621-8335.