Pathology Clinical Consultations 2022 Code Additions

  • Senior Manager, Payor Regulations and Strategy, XIFIN

The 2022 changes to the CPT codebook include a makeover for the Pathology Clinical Consultation section, eliminating the 80500 and 80502 codes that have been in use since 1997. The CAP CPT Editorial Panel proposed a review of the 80500 and 80502 codes after a study identified these services as potentially misvalued in addition to noting discrepancies in code assignment and utilization. Discussion focused on the need for revamping based on the rapid growth in the complexity and volume of laboratory tests, coupled with patients treated for multiple chronic conditions and the drug therapies associated with treatment.

Pathology clinical consultations require a request from a physician or qualified health professional in the same or another institution. Examples of a request could include a written request, electronic request, phone request, or a face-to-face request. Clinical consultations also require the exercise of medical judgment by the consultant physician, and documentation of the consultation report must be filed with the patient’s medical record. Mandated state and federal (e.g., Clinical Laboratory Improvement Amendments [CLIA]) regulations qualify as consultative services.

The AMA’s Society Relative Value Scale Update Committee (RUC) recommended restructuring the code set based on levels of medical decision making, with options for reporting limited, moderately complex, highly complex, and prolonged pathology clinical consultation services. Providers will make their code selection based on the total time spent on consultation services on the date of the consultation or the level of medical decision making (MDM) required to complete the service.

80503 pathology clinical consultation; for a clinical problem, with limited review of patient's history and medical records and straightforward medical decision making when using time for code selection, 5-20 minutes of total time is spent on the date of the consultation. 

80504 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 when using time for code selection, 21-40 minutes of total time is spent on the date of the consultation. 

80505 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 when using time for code selection, 41-60 minutes of total time is spent on the date of the consultation. 

+80506 pathology clinical consultation; prolonged service, each additional 30 minutes (list separately in addition to code for primary procedure).

Codes 80503-80505 report time in 20-minute increments up to 60 minutes. Code 80506 is an add-on-code to the 80505 code that can be added for each additional 15-30 minutes of prolonged service after 60 minutes. If the prolonged service is less than 15 minutes, the 80506 code should not be reported.

Per CPT Chapter Guidelines, the following activities are included in the calculation of consultant time:

  • Review of available medical history, including presenting complaint, signs and symptoms, personal and family history
  • Review of test results
  • Review of all relevant past and current laboratory, pathology, and clinical findings 
  • Arriving at a tentative conclusion/differential diagnosis
  • Comparing against previous study reports, including radiographic reports, images as applicable, and result of other clinical testing
  • Ordering or recommending additional or follow-up testing
  • Referring and communicating with other health care professionals (not separately reported)
  • Counseling and educating the clinician or other qualified health care professional 
  • Documenting the clinical consultation report in the electronic or other health record

The consultant must document the total time personally spent performing the consultation in the medical record to support the service(s) rendered. The calculated time should not include activities performed by clinical staff. 

When billing services based on medical decision making (MDM), the consultant must refer to CPT instructions for determining the appropriate code assignment based on the following categories:   

  • Medical Decision Making (focuses on the number and complexity of problems addressed)
  • Amount and/or Complexity of Data to be Reviewed and Analyzed 
  • Risk of Complications and/or Morbidity or Mortality of Patient Management

Each element used to determine MDM should be clearly documented patient’s report.

Parenthetical notes advise codes 99241-99255 are reported when a consultation includes the examination and evaluation of the patient and codes 80503-80506 are not reported with codes 88321-88325 (Consultation and report on slides prepared elsewhere).

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Published by XIFIN
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