Don’t bank on accepted 88321-88323 unit of service.
Your pathologist consults with an outside lab on slides taken from a 2006 lumpectomy and a 2009 lymph node fine needle aspiration (FNA). That’s 88321 x 2 — right?
Maybe. Your payer determines the answer to that question.
The problem: “Although the American Medical Association (AMA) says the unit of service for pathology consultation codes 88321-88325 is ‘each case,’ CMS begs to differ,” says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., publisher of the Pathology Service Coding Handbook, in The Villages, Fla.
Distinguish CPT Rules
CPT provides three codes for pathology consultations on material referred from an outside institution:
• 88321 — Consultation and report on referred slides prepared elsewhere
• 88323 — Consultation and report on referred material requiring preparation of slides
• 88325 — Consultation, comprehensive, with review of records and specimens, with report on referred material.
The unit of service for codes 88321-88325 is “the surgical pathology case or cytopathology case,” according to the Dec. 2002 CPT Assistant.
The “case” refers to all slides or material associated with a single procedure date. That’s why our opening example of a consultation on slides taken from a 2006 lumpectomy and a 2009 lymph node FNA should be 88321 x 2, per CPT rules.
Tip: “Think of the ‘case’ as all referred material associated with the accession number assigned by the referring lab,” Padget says. “The case might include multiple specimens, but the outside lab normally would include all of them under a single case accession number. Different cases on different days would have different accession numbers.”
For instance: Your pathologist receives two surgical cases for consultation. The first includes slides from a lesion excision dated Feb. 13, 2009, with a melanoma diagnosis, margins not clear. The second includes slides from a re-excision of the lesion site on Feb. 19, 2009. “According to CPT guidelines, we would report this case as 88321 x 2 because the pathologist reviews two cases from two different dates of service,” says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.
Scrutinize MUE and CCI Restrictions
If you’re billing 88321-88325 to Medicare, forget everything you just read. The Medically Unlikely Edits (MUEs) set a limit of “1” for 88321-88325, and the CCI edits bundle these codes with each other.
The CCI Policy Manual states, “CMS payment policy allows only one unit of service for CPT codes 88321, 88323, and 88325 per beneficiary per provider on a single date of service.” CMS goes on to instruct coders not to report the codes on separate claim lines with modifiers in an attempt to receive payment for the services.
“In reality, CMS has set a frequency limit coverage policy for pathology consult codes 88321-88325, allowing only one consultation per beneficiary per day,” explains Padget.
Do this: Regardless of the number of cases, you should not bill Medicare for multiple units of 88321, 88323, or 88325 on the same day. You also shouldn’t bill Medicare for any combination of those codes using modifier 59 (Distinct procedural service).
You may continue to bill multiples of these codes to other payers, as appropriate, when your pathologist performs outside consults on separate surgical pathology or cytology cases in the same day.
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