Principles and Controversies in CPT Coding in Surgical Pathology

Abstract

This article explores basic principles of Current Procedural Terminology (CPT) coding in the text of the American Medical Association (AMA) CPT manual’s surgical pathology section. The sequence of actions in CPT code assignment in a surgical pathology practice is presented. The main controversial issues, as specimen vs container, bundling/unbundling, lymph node regional resection, tissue/procedure vs diagnosis, were discussed. The 1 container 1 specimen compromise at the accession stage is suggested as an assurance of specimen identification integrity. A table of colon specimens’ CPT coding is presented as an example of practical applications. “Frontline” surgical pathology practitioners (ie, accession staff, histotechnologists, pathologists’ assistants, and pathologists) are the article’s targeted audience. Professional coders might extract from the materials a better understanding of the clinical part of the CPT coding in surgical pathology. * CPT : Current Procedural Terminology AMA : American Medical Association HCFA : Health Care Financing Administration HCPCS : Health Care Common Procedural Coding System HIPAA : Health Insurance Portability and Accountability Act PC : professional component TC : technical component LIS : laboratory information system EPIC : Electronic Privacy Identification Center CAP : College of American Pathologists MUE : medically unlikely edits