Current Procedural Terminology (CPT®) coding is part of the everyday routine in surgical pathology laboratory. Accession staff, histotechnologists, pathology assistants, grossing technologist, pathologists’ assistants, and even pathology residents, depending on the institution’s protocols, can be involved in the initial CPT coding owing to computerized process, when CPT® coding is incorporated in the computer specimen accession identification. Histotechnologists and pathologists’ assistants can also help pathologists in determination of the final code/charge during or after the pathology report is issued.

Although the CPT® coding is a well established procedure, there is no any publication that explains specifically for surgical pathology bench workers the basic principles of CPT® coding in all their complexity. CPT® coding and compliance workshops cannot be the sufficient substitute.

The fundamental manual Pathology Service Coding Handbook  published by DLPadget Enterprises, Inc and now maintained by American Pathology Foundation (APF). It is the only comprehensive guidebook to accurate and complete CPT coding for surgical pathology, cytopathology, clinical pathology, and related medical procedures and services that’s currently available. The Handbook targets predominately professional coders and billing managers. Although the Handbook can be useful for many surgical pathology practitioners as a general educational material, all complexities of differences in third party payers are beyond the scope of their responsibilities. The periodically updated almost 500 pages Handbook exists only in electronic form by subscription with a set of rules of its use by Licensing Agreement without printing out for distribution.

The variety of clinical and anatomical faces of surgical pathology specimens opens windows for subjective interpretations of official coding materials. Ambiguous recommendations are not helpful in coding/charge business. The rules must be followed unless they were changed. As Dennis Paget usually remarks “whether a physician or laboratorian agrees or disagrees with the AMA/CAP/CMS prescription for applying the CPT codes isn’t relevant—it’s the AMA/CAP/CMS prescription that must be applied.”

The objective of these reference materials is to present the basic surgical pathology CPT® coding principles and rules from the clinical point of view. Experience indicates that accessioners, histotechnologists, pathologists’ assistants and pathologists need to have an understanding of them so that they can create complete, precise source documentation for the coding professionals. In this way, the operating entity—a physician group practice, a hospital, and/or an independent laboratory—can be reasonably assured that its receipts from payers and insurers are optimal, and secure from potential audit take-back.

CPT® coding official manual is updated every year. These materials will  keep up with the changes related to the surgical pathology coding. However, the main goal of these materials is to facilitate the understanding of principles of CPT® coding in surgical pathology.


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 Web site’s host is thankful to Dennis Padget, MBA, CPA, FHFMA for his critique of the general content of the site: The specific CPT® coding scenarios set forth herein reflect the judgment and advice of the host alone.







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