CPT Questions

December 2003

Q: Is it appropriate to bill for processing and staining specimens-for example, CSF or bone marrow aspirate-when the slide yields nondiagnostic results due to an inadequate specimen or insufficient number of cells?

A. If the specimen is absolutely devoid of cellular elements, it should be designated as unsatisfactory or inadequate for examination, and the pathologist should not charge for an evaluation. If the specimen contains material that is reviewed for diagnostic findings and a report is issued, the pathologist can code and bill for the service, even if the material is too scant to exclude a particular disease process.

Q: We processed an upper lobe posterior segment partial lobectomy followed by an additional partial lobectomy from the same lobe of the lung. Can these services be billed separately, or should they be reported with one code?

A. A specimen is defined by CPT as "tissue or tissues submitted for individual and separate attention, requiring individual examination and pathologic diagnosis." A segmental resection is coded as 88309. If the partial lobectomy was submitted for separate evaluation, it would be appropriate to code it as 88309. The second segment would be coded as an additional unit of 88309. If the specimens are not separately identified or distinctly identifiable, it would be appropriate to report a single unit of 88309.

Frequently asked questions about CPT are published bimonthly in “Capitol Scan.” This section of CAP TODAY is a product of the CAP Economic Affairs Committee.

The codes and descriptions listed here are from Current Procedural Terminology, 4th ed., CPT 2006. CPT 2006 is copyrighted by the American Medical Association. To purchase CPT books, call the AMA at 800-621-8335.

For more information about CPT coding, visit the CPT Coding Resource Center on the CAP Web site.