When our billing company files a claim (s) for
you to your insurance coverage, they must also file a CPT-4 code
for each item of "service" [we must follow federal
demands for billing] and ICD-9 codes for diagnosis.
When our group began with the new hospital in 1971, tissue & transfusion committees assured proper surgical pathology in hospitals & did so solely for the ethical & optimal MEDICAL benefit of the patient. There was no such thing as failure to examine a diseased tissue specimen removed from the body. Today, there are organizations whose greatest concern is cost containment who exert unfluence on what is or is not examined in pathology.
Because so many important (though possibly
rare) diseases are occult (not obvious) in their early phases,
nearly any tissue or body part removed (except for some plastic surgery sculpting specimens) should be sent to pathology for
naked eye (gross) & microscopic examination so that every effort is made to find such diagnoses when that opportunity happens. The importance of seizing the opportunity is reflected in the medical malpractice axiom that "failure to diagnose" is a particularly serious medical failure. Sometimes, a postoperative medical event occurs or an issue surfaces (as with my wife) which may be able to be answered by review of the pathology slides. Even months later, after orthopedic back surgery surgery has failed to satisy the patient and he desires a consult with a competing neurosurgeon, we have been asked to again assess the tissue which was removed (but suppose there was no tissue exam...tissue was discarded in the OR...as happened with my brother-in-law?). Yet, in some sort of attempt to "save the patient money" surgeons sometimes refuse to send the tissue to pathology, even if the surgery center policy says that they must!
Also, sometimes insurers deny your claims payment for surgery without
proof of a pathology exam (as confirmation by another independent physician of what surgery was done).
Then, for each specimen that was sent
to us as a separately identified specimen requiring separate services,
we must file a CPT-4 billing code & an ICD-9 diagnosis code. So, you may have been put
to sleep for what you thought was one operation; but it resulted
(unbeknownst to you) in 1-15 specimens. Even more confusing, if
we perform special tests (special stains, molecular protein expression markers (IHC), genomic tests, chromosome tests, or decalcification) on the specimen,
there are additional CPT-4 charge codes. All of this should be documented
in the pathology report (though it may not be obvious to a layman patient if
you read it). Additionally, there may be charges for our general
help in constantly & contractually influencing that the
lab perform in a way (24/7/365) that works in your best interests.
Pathology CPT coding resource site: at
- Pap smears: this is a complex test arena as to billing & coding rules
[HPV test denial]
- Breast surgery: can have many charges because of varying marker studies which might have to be one to obtain the information needed.
- Thyroid or parathyroid surgery: there can be many encounters between the OR & pathology for "frozen sections" needed to find the abnormal area.
- Gynecological biopsies or surgery: these often require correlation with prior Pap smears for the most optimal effort in your behalf.
- You had a baby: had tubes tied (pathology exam proves that surgery did its job on the tubes) or pathology exam of placenta (to help explain certain non-normal aspects of the pregnancy, labor & delivery, or postpartum period).
- General, thoracic, or vascular surgery:
- general & thoracic: pathology exam is indespensible on all types of organs removed or biopsied generally or in the chest cavity. Even bariatric (obesity)
surgery specimens have yielded significant findings in our lab, the jejunal segment always inspected for evidence of protein sensitive enteropathy and sleeve gastrectomy specimens for Helicobacter gastritis (maybe 2-4% of "sleeve" gastrectomies have it [L08-5767, L08-11800]) and polyps.
- vascular surgery: carotid endarterectomy and other vascular surgery specimens are examined under the microscope to assess whether the problem was
due to atherosclerotic degenerative disease, granulomatous or other vasculitis, or amyloidosis or some other rare disease. And this microscopic assessment discerns
how much of an atherosclerotic lesion is poorly stable atheroma [L09-2526]. Poorly stable atheromas embolize much more readily during surgery. But, unexpected
embolic or ischemic sequelae at surgery in the face of a plaque microscopically found to be predominantly stable might suggest an undiagnosed thrombophilia (such
that tiny clots form & shed & reform during & after surgery). We look for evidence of primary or embolic septic or myxothrombotic change in aorticofemoral types. We DO NOT
attempt to to document the percentage of stenosis as determined clinically by exquisite vascular studies because the surgical artifact introduced by the process of
atherectomy causes a total lack of correlation [L09-9366].
- You had a non-kidny biopsy (FNA) by radiologist
in radiology; or by a pathologist
- You had a medical kidney biopsy by radiologist
in radiology. These are initially handled by our local pathologist who (1) helps assure that adequate biopsy specimens are taken for the medical problem in question, (2) determines if the situation requires any urgent local preliminary diagnosis, (3) divides the sppecimens appropriately into the different shipping media for light/ EM microscopy and immunomicroscopy.
- Lung problems: medical lung biopsies frequently are additionally forwarded for expert pathology consultation or molecular markers.
- Bone marrow specimens: much co-ordination of analysis be various lab sections and even other remote labs goes on behind the scenes.
- Dermatologist and skin biopsies and surgery: it is advantageous to have local pathologist exam who then has ready access to an expert dermatopathologist when desired or deemed needed.
- Orthopedic and/or podiatric bone, joint, or foot surgery: the pathology exam is in search of(1) documenting what was removed and (2) discerning coincidental occult bone and joint diagnoses having to do with crystallosis or as yet asymptomatic infection-stimulated or auto-immune stimulated, immuno-arthropathies such as reactive synovitis or rheumatoid arthritis, etc.
- Orthopedic or neurosurgical back-surgery specimens: as collapsed vertebra can be due to cancer, biopsy is often taken at kyphoplasty; and, as noted in the above introduction, exam of other back specimens protects the patient's interests as above noted.
- Bleeding or clotting problem consultations: we had not bothered to bill the pathologists value in this critical utilization of the laboratory.
- Ear, Nose, and Throat (ENT) and/or oral-surgery/dental surgery: these provide protections to patients as above.
- Gastrointestinal (from endoscopy)
and liver biopsies: the pathologist often must investigate the medical record, request information from the endoscopy report, and even proactively obtain some additional tests to render optomal diagnosis (and use expert consultation when needed)...an especially prime area for the positive difference that "point of service pathology" makes for the patient.
- Urological biopsy and surgery: it is a crucial advantage in the patients favor when prostatectomy cases for cancer can be analysed in the same lab diagnosing the pre-operative prostate biopsies. [core biopsies]
(posted 26 April 2001; latest update 6 July 2014)