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Code 88325 is utilized to report a comprehensive consultation in surgical pathology or cytopathology, specifically when a case is referred to an outside pathologist or facility for expert evaluation. This code encompasses a thorough review of the patient's medical records and specimens, ensuring that the consulting pathologist has a complete understanding of the patient's clinical history and current health status. The process begins with the consulting pathologist examining the patient chart, which includes essential information such as medical history, current clinical status, and any reports from oncologists that detail diagnoses and treatments. Additionally, the pathologist reviews all relevant laboratory tests and results that support the clinical picture. The consultation involves a meticulous examination of the submitted slides and/or tissue blocks, which may include various diagnostic techniques such as special stains, immunohistochemistry, and immunofluorescence. The consulting pathologist integrates these findings into a comprehensive report, which is a critical document that outlines the identification of each specimen or package of slides reviewed. The report also details the chart records and laboratory tests that were considered during the consultation. Ultimately, the final diagnosis is presented, accompanied by supporting remarks that reflect the clinical expertise of the consultant. This process may also include the identification of other clinicians who were involved in the review, ensuring a collaborative approach to patient care and diagnosis.
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The procedure associated with CPT® Code 88325 is indicated in various clinical scenarios where a comprehensive evaluation of pathology or cytopathology specimens is necessary. The following conditions may warrant such a consultation:
The procedure for CPT® Code 88325 involves several critical steps to ensure a thorough and accurate consultation. Each step is essential for the comprehensive evaluation of the referred material:
After the completion of the consultation process associated with CPT® Code 88325, the consulting pathologist provides a comprehensive report to the referring physician. This report serves as a critical document for guiding further clinical decision-making. The referring physician may use the insights and recommendations provided in the report to adjust treatment plans, seek additional consultations, or monitor the patient's condition more closely. It is essential for the referring physician to review the findings thoroughly and consider them in the context of the patient's overall treatment strategy. Additionally, the consulting pathologist may be available for follow-up discussions to clarify any aspects of the report or to provide further insights based on the findings.
| Short Descr | CONSLTJ COMPRE RVW REC REPRT | Medium Descr | CONSLTJ COMPRE RVW RECORD REPRT REFERRED MATRL | Long Descr | Consultation, comprehensive, with review of records and specimens, with report on referred material | 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 | 227 - Other diagnostic procedures (interview, evaluation, consultation) |
This is a primary code that can be used with these additional add-on codes.
| 0840T | Add On Code Resequenced Code MPFS Status: Carrier Priced APC N Digitization of glass microscope slides for consultation, comprehensive, with review of records and specimens, with report on referred material (List separately in addition to code for primary procedure) |
| 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. | GC | This service has been performed in part by a resident under the direction of a teaching physician | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | 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. | CR | Catastrophe/disaster related | GW | Service not related to the hospice patient's terminal condition | 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 | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | 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 | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | 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 |
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| 2024-01-01 | Changed | Short and Medium Descriptions changed. |
| 2024-01-01 | Note | Guideline added. |
| Pre-1990 | Added | Code added. |
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