CPT Case Scenarios in Surgical Pathology Subspecialties

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CPT is a registered trademark of the American Medical Association.”

 The well known method of case scenarios and examples is in the background of these materials. Case scenarios show the process of CPT coding in surgical pathology every day practice by highlighting common difficulties and mistakes.

The nature of human inquiry is in finding an answer to a concrete situation using the shortest and fastest track. If dermatopathology question comes up, at this moment nobody is interested in gynecology. This is an explanation why the case scenarios are presented in subspecialties. Legal system uses precedents, cooking employs recipes. CPT coding in surgical pathology can be the best explained by case scenarios and examples.

The subspecialties were divided in nine groups:


Lymph/hemo pathology




Lung & Heart

Soft & Hard (bones) tissue

Head & Neck


A separate section will present intraoperative consultations. It includes predominately frozen section as well as cytology examination in surgical pathology specimen.

All cases have been simulated with a close resemblance to the actual clinical event. Details unrelated to CPT coding were omitted. The pathology diagnoses were simplified to adjust to the CPT coding purposes. Some data from gross description were added in particular cases to clarify coding decisions. Most of the case scenarios have a subtitle of the main coding topic that the case represents. The emphasis has been made on controversial coding situations.

The case scenarios have a similar table format: accession (preliminary coding) according to the requisition’s form specimen description and the final billing code after the pathologist’s report with the sign-out diagnosis. The changes made by the pathologist or billing manager are typed in bold. The tabular form of case scenarios reflects the Laboratory Information System (LIS) programs computer screen which is in front of the practitioner.

Each subspecialty section is prefaced with relevant official descriptors of codes from AMA’s CPT manual (typed in italic). Some of the descriptors have comments.

A separate table presents suggestions of codes with comments (if necessary) for unlisted in CPT manual descriptors of specimens in alphabetic order.

In many occasions, a reference to a relevant case scenario or example is placed in parentheses after the descriptor (for example Case #1, 2, 3, etc.). If the reference were to a specific type of specimen, a letter is placed after the case number (for example Case # 2-A, B, C, etc.).

Institutions have different ways for managing correct coding. Some institutions have a special technical assistant which oversees the coding. Histotechnologists in small laboratories might be in charge for coding.

The presented case scenarios reflect the most standard sequence of coding events:

Accession- preliminary CPT code

The pathologist’s sign out of the pathologist’s report

The final billing manager’s correction according to the pathologist’s report.

The table 1 summarizes the sequence of actions while the CPT code is generated in surgical pathology laboratory. With some local deviations, this pattern is universal.


Coding   phase Participants Actions
 Accession upon specimen   receipt  Accession   staff  Matching   the requisition form with LIS CPT computer dictionary
Specimen   assessment Grossing   techniciansPathologists’   assistants ResidentsPathologist Draft   grossing reportSign-out pathologists’   reportCPT code/s corrections
 Charge finalization Billing   manager Matching   CPT code/s with the pathologists’ sign-out report and billing provisions;   credits if applied

Accession can be assigned to special accession person, histotechnologist, grossing technologist, pathology assistant, but usually this work is treated, unjustified, as an entry level. Some institutions practice instant billing for the technical component (TC) with an established mechanism to validate or correct the preliminary (accession) code based on the final diagnosis by the professional billing manager or technical assistant.

The pathologist bears an ultimate responsibility for correct coding. Usually, pathologists rely on the professional billing managers in large institution or histotechnologists in small laboratories. As an ideal situation, the billing manager should permanently communicate with the pathologist regarding the final coding especially in questionable cases, but in practice it is more a wish.

Most CPT coding cases do not require explanations or examples because they do not have any difficulty. They are not even mentioned assuming that user simply picks the appropriate descriptors of the CPT coding manual, especially keeping in mind that they are hopefully correctly incorporated in the CPT coding LIS computer dictionary. Every case scenario is accompanied by explanation of coding choice, sometimes extended owing to the complexity of the issue.

Although some case scenarios look cumbersome and overcrowded by repetition of simple coding assessments, they reflect a real clinical situation. Often monotonous and boring, similar coding situations illustrate basic rules and principles of CPT coding. Simple and complicated coding situations are interspaced in “advanced” cases. It does not make any sense and actually impossible to present examples of all coding situations, especially if they do not generate any difficulty, as it is in most cases thanks to laboratory information systems (LIS).

Some case scenarios display wrong CPT codes that were for many reasons assigned during accession or even after sign out. They reflect real practice difficulties which practitioners can recognize as similar to their experiences.

The case scenarios sections are not designated for a systematic but rather for a selective reading, just for a specific case in question, like a recipe in a cookbook. The listed official AMA manual’s and suggested unlisted CPT codes can provide reference to a case scenario with a referring number.

Before placing the obligatory Disclaimer, it would be right to say some informal words.  Although all recommendations try to reflect AMA, CAP, CMS, and official letters as published guidance, there is space for interpretations and common sense applications. The goal is to alert the practitioners to areas of difficulty and controversy. Otherwise it would not be necessary to write these materials. However, in the end of the day it is about payment and their regulation and standardization. All payments are local. They are determined in vast majority of cases by local Medicare contractors, Medicaid agency, or private insurance company.


The host does not warrant that the information provided herein represents CPT coding advice that is acceptable to government payers and private insurers; therefore, the host accepts no responsibility for liability or damages that a user might incur if the information contained in the website is contrary to that accepted by a government payer or a private insurer.


The host is thankful to Elizabeth Sheppard, MBA, HT (ASCP) for her contribution to the design of the case scenarios framework.




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