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Intraoperative Consultation

Intraoperative consultations, which include frozen section analysis during surgery, represent a substantial portion of the surgical pathology workload. Proper CPT coding of these consultations is important for ensuring surgical pathology departments receive deserved reimbursement. Two key elements must be present for an intraoperative consultation to be coded: a formal clinical request and a written pathology report. While frozen sections ideally provide results during surgery, in practice surgery may finish before analysis is complete.

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421 views2 pages

Intraoperative Consultation

Intraoperative consultations, which include frozen section analysis during surgery, represent a substantial portion of the surgical pathology workload. Proper CPT coding of these consultations is important for ensuring surgical pathology departments receive deserved reimbursement. Two key elements must be present for an intraoperative consultation to be coded: a formal clinical request and a written pathology report. While frozen sections ideally provide results during surgery, in practice surgery may finish before analysis is complete.

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teacherashley
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Intraoperative Consultation

Intraoperative consultation encompass following CPT codes:


88329 Pathology consultation during surgery;
88331 first tissue block, with frozen section (s), single specimen
88332 each additional tissue block with frozen section (s)
Intraoperative cytological consultation is presented in CPT manual by two codes
88333 Pathology consultation during surgery; cytologic examination (e.g. touch prep, squash prep),
initial site
88334 Pathology consultation during surgery; cytologic examination (e.g. touch prep, squash prep),
each additional site
Intraoperative consultations, or its main portion as frozen sections, are substantial part of surgical
pathology work load and consequently CPT coding for charge. There are some details that should be
addressed for efficient coding work in the laboratory. The question of coding intraoperative
consultation appears often at the Pathology/Lab Coding Discussion Group, as well as sometimes on
Histonet.
Surgical pathology looses legitimately deserved revenues by cavalierly approach to details and
documentation. The coder ought to be provided with additional materials that might be disguised in
technical details.
In the ideal world, a frozen section must be rendered with a pathologists report while the surgery is
still in progress, but this is not the case in surgical practice. It happens that the surgery is finished
before the frozen section is finished. In any event, for code an intraoperative consultation two
features must be present: clinical formal request for intraoperative consultation and written
pathologists report.
Frozen section were mentioned in case scenarios in subspecialties, but details were omitted to
simplify them to concentrate on the main course of the process
Now with the spread of guided invasive diagnostic procedure, intraoperative consultation might be
not only directly from the operation, but it can be in a radiology suit (ultrasound or CT scan) or
elsewhere. However, in opposite to cytopathology when immediate studies of fine needle aspiration
(FNA) are a routine, the surgical pathology rarely uses this service in practice besides frozen section.
As an example, of an intraoperative consultation, can be mentioned radiology guided kidney biopsy.
However, usually pathology assists in confirmation of adequacy of the biopsy material by technical
staff that cannot be coded, but if in rare occasions pathologists participates in this procedure; the
intraoperative consultation is not issued.
In theory, code 88329 can be posted if the examination is performed though in practice it is rarely.
Case #1 Gross intraoperative evaluation Multiple blocks on Frozen Section
A 71-year-old woman with history of hysterectomy (20 years old) underwent bilateral salpingo-
oophorectomy due to suspicion of a malignant right ovary. Five specimens were sent (two for frozen
section) to pathology.

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