Health Information Management

Tip: Determine the number of specimens to code surgical pathology correctly

APCs Insider, November 6, 2009

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If you perform a level IV surgical pathology (88305) on more than one specimen from the same patient, the unit of service for this code is the number of specimens requiring individual exam and pathologic diagnosis. Use modifier -59 to indicate tests provided for different specimens.
 
If you test a single specimen, report only the code that describes the highest level of specificity within a group of related codes if the tests are performed on a specimen with the same end result. For example, within the code range of 88104–88112, report only one code. If you perform multiple tests on multiple specimens, use modifier -59.
 
This tip was adapted from the article “Q&A: Determining the proper use of modifier -59” in the November issue of Briefings on APCs.



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