![]() They are more technical than medical issues, if they are applied appropriately and supported by the pathology report. Special stains and other so-called “add-on” procedures are separately coded. If the main code is incorrectly chosen, modifiers and other coding techniques (the realm of billing managers) cannot help. This article only touches on the specimen’s main CPT code. The same principles and methods can be used in different coding situations (eg, gastroenterology, gynecology, urology, etc). As a methodological educational tool, this article tries to give a general approach to CPT coding in dermatopathology, as an example, with concentration on details, as well as on disputable and intricate issues. The presented case studies and examples demonstrate common reasons for mistakes that might be the grounds for potentially damaging overcharges as well as unnecessary loss of revenue. In dermatopathology, these circumstances have practical significance due to the variety of clinical diagnostic situations. Pathologists are also sometimes ignorant of the principles of CPT coding, let alone knowing CPT coding in detail. Pathologists, overwhelmed by the amount of cases and preoccupied with diagnostic problems, may be far away from everyday supervision of CPT coding, or the support staff may not be familiar with the details of diagnoses in individual cases as far as correct coding is concerned. Skin only appears to be a relatively simple task for CPT coding, but mistakes do occur. Publications, like this presented article, can discuss deficiencies in the CPT manual with a presumed hope that coding authorities (the AMA and the College of American Pathologists ) will make adjustments. The CPT coding is the official regulation that must be followed, even if the performing physician feels the system is unfair in a particular situation. The principle of CPT coding in surgical pathology is that named specimens are classified by code based on the “average” physician work/time. In contrast to the CPT code assignment, which is governed by the AMA’s rules, the dollar amount charged per code is up to each physician and institution. 1 The CPT manual is a copyrighted text that’s owned and maintained by the American Medical Association (AMA). Charge codes assigned for surgical pathology services are regulated by the Current Procedural Terminology (CPT) manual’s taxonomy and instructions.
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