Surgical Pathology Evaluation and Management (E&M)

There is no reason a surgical pathologist cannot see a patient in the office setting to perform an evaluation and management (E&M) service (99211 - 99215).  This rarely occurs, but as licensed physicians, they are capable of evaluating a patient, rendering a diagnosis, and prescribing a treatment plan.


In fact, this is what surgical pathologists do all the time, they just do not see the patient in person. Rather, they examine and diagnose a portion of the patient.  To a pathologist, the equivalent of E&M codes are the surgical pathology codes they use to describe specimens, in average levels of expected complexity.  


When a pathologist renders a diagnosis on a surgical specimen, he or she is rendering a diagnosis for the patient.  The tissue is diagnosed, and, because the tissue belongs to the patient, the diagnosis belongs to the patient.  Whether systemic signs and symptoms are visible, the pathological diagnosis still applies to the patient.


When a surgical pathologist, or a heme pathologist, recommends further clinical correlation, they are recommending a further consideration for the patient's care plan.  They are not equivocating on the diagnosis they have supplied for the patient.

Unlisted specimen: Heart

While many laboratories may not see entire hearts being submitted as surgical pathology specimens, there are places that do get them on a fairly regular basis.  An entire heart is an unlisted specimen in CPT.  Even if your lab will never receive a heart, the same notions apply to assigning a CPT code to a heart, as would be the case with any other unlisted specimen.

While CPT does have a comprehensive list of 225 possible specimens,  I've got an additional forty or so that I've come across over the years, that are not listed in CPT.  Knowing how to think of these odd tissues leads to appropriate coding.

I extended the subscription date last month by another five days, and that seemed to work well for people  who needed time to think it over.  The same deal will apply for July.  While the latest issue comes out on the first of every month, it is not reissued.  People signing up for a 6-month subscription by July 5, will receive July through December issues.  People subscribing after July 5, will receive subscriptions beginning August 1.

Subscribe today!

Subscription offer

Ever wonder the difference between a simple excision and an extensive resection?  The precise meaning and rationale behind all the different prostate specimens?  Prostate TUR?  Prostate Biopsy? Prostate, radical resection?  Prostate, other than radical resection?  88305, 88309, or 88307?

The Surgical Pathology Coding Newsletter describes one surgical pathology specimen each month, in depth.  Subscribe for six months of the newsletter for a very reasonable $25.00.  Subscriptions received prior to June 5, 2011 will be sent out as a pdf document (this is an electronic newsletter only at the moment) on June 6.  Subscriptions received after June 5, will begin on July 1st, 2011.  The June issue deals with Thyroid, total/lobe (88307), lymph nodes, parathyroid glands, margins, and other issues.  It can be both more complicated and simpler than many people think.

Subscribe today!