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36.4.22.3 Clinical Pathology Consultations
Procedure codes 3-80500 and 3-80502 should be used for clinical pathology consultations.
Providers may be reimbursed for clinical pathology consultation when the claim indicates the following information:
• The request is initiated by the client's attending physician and includes the name and address or provider identifier of the physician requesting the consultation.
•The request relates to a test result that lies outside the normal or expected range in view of the condition of the patient.
•The patient's diagnosis.
•The clinical test(s) requiring the consultation.
•A written narrative report describing the findings of the consultation, which will also be included in the client's medical record.
If the claim does not include all of this information, the clinical pathology consultation will be denied.
Clinical pathology consultations cannot be paid for surgical and anatomical pathology services or any other pathology services payable in an inpatient hospital (POS 3) and an outpatient hospital (POS 5) (e.g., bone marrows, gross and microscopic exam, etc.).
A pathology consultation must always involve medical interpretive judgment that ordinarily requires a physician. Routine conversations held between a pathologist and attending physicians about test orders or results are not consultations.
Generally, only one clinical pathology consultation should be allowed per day by the same provider. Additional consultations per day, with supporting documentation of medical necessity, will be considered for payment on an individual basis.
Certain procedures are not usually performed by a pathologist, such as the following procedure codes used for office, outpatient, or inpatient consultations:
Therefore, if these procedures should be billed by this specialty type, the procedure code will autodeny with the message, "This procedure not covered for this provider specialty." Payment will be considered on an individual appeal basis if a pathologist can document the medical necessity of performing these procedures.
The specialties designated for pathologists are listed in the following table:
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