- Payments for Pathology Services
- Medicare Physician Fee Schedule
- Implementation Tips for CAP-Developed Pathology Consult Codes for 2022
- Pathology Clinical Consultation Code Frequently Asked Questions
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The key distinction for the new pathology consultation services is code selection based on total time or the complexity of medical-decision making.
Per CPT guidance, 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.
Yes. At a minimum, we recommend that the pathologist document the request (eg, written request, electronic request, phone request, or face-toface request) and clinical consultation report in the electronic or other health record.
Please see CAP 2022 Medicare Physician Fee Schedule (MPFS) Impact Table and webinar presentation for reimbursement rates and RVUs for new pathology clinical consultation service codes 80503, 80504, 80505, and 80506.
Per the CPT instruction, the selection of the appropriate level of (pathology clinical consultation) services may be based on either the total time for pathology clinical consultation services performed on the date of consultation or the level of medical decision making as defined for each service.
Yes. With regard to E/M services, the AMA CPT guidance instructs that the methodology that accounts for the most appropriate and relevant elements for a given patient encounter should be used to select the appropriate codes. For example, a high-intensity E/M visit that lasts a short period of time may be more accurately reflected using MDM; whereas a time-intensive E/M visit might be better captured using time as the criteria for code selection.
We believe that the CPT guidance may also be applied to the Pathology Clinical Consultation services. Thus, we encourage pathologists to review the MDM criteria as well as the Time criteria to determine what best describes the pathology clinical consultation service that is provided.
The appropriate time should be documented in the medical record when it is used as the basis for code selection. For coding purposes, the time for these services is the total time on the date of the consultation. It includes time personally spent by the consultant on the day of the consultation and time in activities that require the consultant. It does not include time in activities normally performed by clinical staff.
The best place for instructions on the complexity is to review the Medical Decision Making (MDM) guidelines for code selection. The MDM guidelines are available in the 2022 CPT® codebook. You can contact CAP Advocacy CPT staff email@example.com for more details.
According to the CPT Coding Guidance, the CPT coding instruction does not direct a hospital or laboratory policy on standing orders as it involves payment policy. Per CPT guidance for codes 80503-80506, 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). At a minimum, we recommend that the pathologist document the request (eg, written request, electronic request, phone request, or face-to-face request) and clinical consultation report in the electronic or other health record.
Eligibility for payment, and coverage policy, is determined by each individual insurer or third-party payer.
According to the 1997 Federal Register:
“(Clinical consultation services), require that a clinical consultation meet four criteria before it can be paid. One of these criteria is that the clinical consultation must be requested by the patient’s attending physician. As we indicated in the preamble to the proposed rule, we have allowed a standing order policy to be used as a substitute for the individual request by the patient’s attending physician since a 1984 lawsuit. However, we believe that this policy is no longer appropriate. Because the policy was not embodied in the court’s judgment or otherwise required by law and because we view it as creating opportunities for abuse and waste, effective January 1, 1998, we are not accepting a standing order as a substitute for the individual request by the attending physician. We are instructing the Medicare carriers to enforce § 415.130(b) as it is presently written.”
Per the CPT instruction, the order can come from another physician or other qualified health care professional at the same or another facility or institution.
Using these codes for tumor boards or other case conferences is not appropriate unless there is a specific request, or documented order, from an individual provider on a specific clinical question on an individual patient. The consultant pathologist must add additional interpretative medical judgement that was not present in the original report. The consultant must also meet all other service requirements for reporting the Pathology Clinical Consultation codes.