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Official Description

Consultation and report on referred slides prepared elsewhere

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 88321 is utilized when a physician offers consultative advice regarding slides that have been prepared at a different facility or location, rather than within the physician's own office. This code specifically applies to situations where the physician reviews these referred slides and generates a report based on their findings. It is important to distinguish this code from CPT® Code 88323, which pertains to instances where the physician not only provides consultative advice but also prepares slides from tissue or cell samples that have been collected elsewhere and sent to the physician's office. In summary, 88321 is focused on the consultation and reporting aspect of slides prepared externally, emphasizing the physician's role in evaluating and interpreting the provided materials without engaging in the slide preparation process themselves.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The use of CPT® Code 88321 is indicated in scenarios where a physician is called upon to provide expert consultative advice on histological slides that have been prepared at an external facility. This may occur in various clinical contexts, including but not limited to the following:

  • Second Opinion The physician may be asked to review slides for a second opinion on a diagnosis made by another pathologist.
  • Complex Cases The physician may need to evaluate slides related to complex or rare cases that require specialized expertise.
  • Quality Assurance The review may be part of a quality assurance process to ensure the accuracy of diagnoses made by other facilities.

2. Procedure

The procedure associated with CPT® Code 88321 involves several key steps that ensure a thorough evaluation of the referred slides. Each step is critical to the overall consultative process:

  • Step 1: Receipt of Slides The physician receives the histological slides that have been prepared at an external facility. This may include a variety of tissue types and conditions that require careful examination.
  • Step 2: Review of Clinical Information Prior to examining the slides, the physician reviews any accompanying clinical information or history provided with the slides. This context is essential for accurate interpretation and diagnosis.
  • Step 3: Microscopic Examination The physician conducts a detailed microscopic examination of the slides, assessing cellular morphology, tissue architecture, and any pathological changes present. This step is crucial for forming an accurate diagnosis.
  • Step 4: Report Preparation After the examination, the physician prepares a comprehensive report detailing the findings, interpretations, and any recommendations based on the review of the slides. This report serves as a formal consultative document for the referring physician.

3. Post-Procedure

Following the completion of the consultative process associated with CPT® Code 88321, the physician may provide feedback to the referring physician based on the findings documented in the report. There are no specific post-procedure care requirements for the physician, as the process primarily involves the review and reporting of slides. However, it is essential for the referring physician to consider the consultative report in the context of patient management and treatment decisions. Additionally, the physician may be available for further discussion or clarification regarding the findings if needed.

Short Descr CONSLTJ&REPRT SLD PREP ELSWR
Medium Descr CONSLTJ&REPRT REFERRED SLIDES PREPARED ELSEWHERE
Long Descr Consultation and report on referred slides prepared elsewhere
Status Code Active Code
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator STV-Packaged Codes
Type of Service (TOS) 3 - Consultation
Berenson-Eggers TOS (BETOS) T1G - Lab tests - other (Medicare fee schedule)
MUE 1
CCS Clinical Classification 234 - Pathology

This is a primary code that can be used with these additional add-on codes.

0838T Add On Code Resequenced Code MPFS Status: Carrier Priced APC N Digitization of glass microscope slides for consultation and report on referred slides prepared elsewhere (List separately in addition to code for primary procedure)
GC This service has been performed in part by a resident under the direction of a teaching physician
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
X5 Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician
CR Catastrophe/disaster related
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
91 Repeat clinical diagnostic laboratory test: in the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91. note: this modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. this modifier may not be used when other code(s) describe a series of test results (eg, glucose tolerance tests, evocative/suppression testing). this modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
PD Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
GY Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
26 Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
77 Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
95 Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
GZ Item or service expected to be denied as not reasonable and necessary
KX Requirements specified in the medical policy have been met
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
Q3 Live kidney donor surgery and related services
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
Date
Action
Notes
2024-01-01 Changed Short and Medium Descriptions changed.
2024-01-01 Note Guideline added.
Pre-1990 Added Code added.
Code
Description
Code
Description
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