On November 2, the Centers for Medicare & Medicaid Services (CMS) released the final 2022 Medicare Physician Fee Schedule, which included the CAP-developed pathology consultation services codes and values. Pathologists will have the new CPT codes for pathology clinical consultation services in 2022. The CAP worked with the American Medical Association’s (AMA) CPT Editorial Panel to establish pathology clinical consultation codes and develop new payment rates through the CAP’s role in the AMA/Specialty Society Relative Value Scale Update Committee (RUC). The CMS accepted most of the CAP-developed relative values for the pathology clinical consultation services.
The new CPT coding structure should improve the physician service reporting and billing process for pathologists due to improved instructions and a “Time” or “Medical Decision Making” (MDM) basis for code selection. The distinction among the new code family involves a degree of complexity and/or time of service, broken down by 20-minute increments each for codes 80503, 80504, and 80505, along with an add-on code 80506 reflecting additional 15-30 minutes above that spent on CPT 80505.
Pathology clinical consultation; for a clinical problem, with limited review of patient's history and medical records and straightforward medical decision making
Pathology clinical consultation; for a moderately complex clinical problem, with review of patient’s history and medical records and moderate level of medical decision making
Pathology clinical consultation; for a highly complex clinical problem, with comprehensive review of patient’s history and medical records and high level of medical decision making
|÷80506||Pathology clinical consultation; prolonged service, each additional 30 minutes (List separately in addition to code for primary procedure)|
Use 80506 in conjunction with 80505.
Pathology clinical consultation services codes (80503, 80504, 80505, 80506) describe physician pathology clinical consultation services. A pathology clinical consultation is a service, including a written report, rendered by the pathologist in response to a request (eg, written request, electronic request, phone request, or face-to-face request) from a physician or other qualified health care professional that is related to clinical assessment, evaluation of pathology and laboratory findings, or other relevant clinical or diagnostic information that requires additional medical interpretive judgment. Reporting pathology and laboratory findings or other relevant clinical or diagnostic information without medical interpretive judgment is not considered a pathology clinical consultation.
The pathology clinical consultation services (80503, 80504, 80505, 80506) may be reported when the following criteria have been met:
- The pathologist renders a pathology clinical consultation at the request of a physician or other qualified health care professional at the same or another institution.
- The pathology clinical consultation request is related to pathology and laboratory findings or other relevant clinical or diagnostic information (eg, radiology findings or operative/procedural notes) that require additional medical interpretive judgment.
A pathologist may also render a pathology clinical consultation when mandated by federal or state regulation (eg, CLIA).
To assist the health care system in an orderly annual transition to a newly modified CPT code set, the AMA releases each new edition ahead of the January 1 operational date and develops an insider’s view with detailed information on the new changes in the 2022 CPT code set.
Coding books and products, including the CPT Professional 2022 codebook, are available from the AMA Storefront on Amazon. The 2022 CPT codes and descriptors can be imported straight into existing health care software solution using the downloadable CPT 2022 Data File. The file contains the updated code set’s complete descriptor package, including official descriptors for consumers and physicians, and the complete official CPT coding guidelines.
For more information on the 2022 Pathology Consultation Codes, please refer to the Frequently Asked Questions.