2025 CPT code 88321
(Active) Effective Date: N/A Pathology and Laboratory Procedures > Surgical Pathology Procedures Feed
Consultation and report on referred slides prepared elsewhere.This includes review of special stain, IHC, immunofluorescence, and other special procedure slides and test data.
Modifiers may be applicable.For example, modifier 59 may be used to indicate a distinct procedural service.
Medical necessity is established by the need for a second opinion from a specialist or expert.
The consulting pathologist receives a consultation request and prepared slides. They review the slides, potentially including multiple slide types and body areas, and prepare a report detailing their evaluation and opinion.The consultation occurs after an initial diagnosis elsewhere.
In simple words: A pathologist reviews slides and test results from another facility to provide a second opinion.This includes special tests like IHC and immunofluorescence.
This code represents a consultation and report on slides prepared elsewhere. It includes the review of special stain, IHC, immunofluorescence, and other special procedure slides and test data prepared and initially interpreted at the referring facility. The unit of service is the surgical case, regardless of the number of slides received. The number of individual specimens represented by the case does not change the code selection.Clinical history, pathologic diagnosis, and complexity do not justify using a higher level code.
Example 1: A patient has a biopsy in one hospital, and the slides are sent to a specialist at another hospital for a second opinion., A patient with a rare cancer has their slides reviewed by an expert in another state., A surgeon requests a second opinion on slides from a pathology lab in a different city.
Documentation should include the consultation request, the original pathology report, and the consultant's report.
** If the consultant's lab prepares additional routine slides, these cannot be billed separately. Add-on code 0838T is used when the digitization of glass microscope slides is performed.
- Revenue Code: T1G - LAB TESTS - OTHER (MEDICARE FEE SCHEDULE)
- Specialties:Pathology
- Place of Service:Independent Laboratory, Office