Department of Pathology and Laboratory Medicine
Pathology Consultation Guidelines
86077 (1.26 rvu) Blood bank physician services; difficult cross match and/or evaluation of irregular antibody(s), interpretation and written report
86078 (1.3 rvu) Blood bank physician services; investigation of transfusion reaction including suspicion of transmissible disease, interpretation and written report
86079 (1.29 rvu) Blood bank physician services; authorization for deviation from standard blood banking procedures (eg, use of outdated blood, transfusion of Rh incompatible units), with written report
99195 (.45 rvu) Phlebotomy, therapeutic (separate procedure)
36520 (3.77 rvu) Therapeutic apheresis (plasma and/or cell exchange)
Clinical pathology consultation (limited or comprehensive)
A clinical pathology consultation is a service, including a written report, rendered by the pathologists in response to a request from an attending physician in relation to a test result(s) requiring additional medical interpretive judgment.
Reporting of a test result(s) without medical interpretive judgment is not considered a clinical pathology consultation.
80500 (0.58rvu) Clinical pathology consultation; limited, without review of patient's history and medical records
80502 (1.68rvu) Clinical pathology consultation; comprehensive, for a complex diagnostic problem, with review of patient's history and medical records
(These codes may also be used for pharmacokinetic consultations)
(For consultations involving the examination and evaluation of the patient, see 99241-99275)
Confirmatory Consultations (99271-99275) New or Established Patient
The following codes are used to report the evaluation and management services provided to patients when the consulting physician is aware of the confirmatory nature of the opinion sought (eg, when a second/third opinion is requested or required on the necessity or appropriateness of a previously recommended medical treatment or surgical procedure).
Confirmatory consultations may be provided in any setting.
A physician consultant providing a confirmatory consultation is expected to provide an opinion and/or advice only. Any services subsequent to the opinion are coded at the appropriate level of office visit, established patient, or subsequent hospital care. If a confirmatory consultation is required, eg, by a third party payor, the modifier ‘-32’ or 09932, mandated services, should also be reported. (See also Consultation notes, page 18). Typical times have not yet been established for this subcategory of services.
99271 (.81rvu) Confirmatory consultation for a new or established patient, which requires these three key components:
• a problem focused history;
• a problem focused examination;
• and straightforward medical decision making.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are self limited or minor.
99272 ( 1.29 rvu) Confirmatory consultation for a new or established patient, which requires these three key components:
• an expanded problem focused history;
• an expanded problem focused examination;
• and straightforward medical decision making.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of low severity.
99273 ( 1.81rvu) Confirmatory consultation for a new or established patient, which requires these three key components:
• a detailed history;
• a detailed examination;
• and medical decision making of low complexity.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of moderate severity.
99274 ( 2.45rvu) Confirmatory consultation for a patient, which requires these three key components:
• a comprehensive history;
• a comprehensive examination;
• and medical decision making of moderate complexity.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of moderate to high severity.
99275 ( 4.22rvu) Confirmatory consultation for a patient, which requires these three key components:Confirmatory consultation for a patient, which requires these three key components:
• a comprehensive history;
• a comprehensive examination;
• and medical decision making of high complexity.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of moderate to high severity.
99371 (.22rvu) Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care professionals (eg, nurses, therapists, social workers, nutritionists, physicians, pharmacists); simple or brief (eg, to report on tests and/or laboratory results, to clarify or alter previous instructions, to integrate new information from other health professionals into the medical treatment plan, or to adjust therapy)
99372 (.44rvu) Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care professionals (eg, nurses, therapists, social workers, nutritionists, physicians, pharmacists); intermediate (eg, to provide advice to an established patient on a new problem, to initiate therapy that can be handled by telephone, to discuss test results in detail, to coordinate medical management of a new problem in an established patient, to discuss and evaluate new information and details, or to initiate new plan of care)
99373 (.65rvu) Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care professionals (eg, nurses, therapists, social workers, nutritionists, physicians, pharmacists); complex or lengthy (eg, lengthy counseling session with anxious or distraught patient, detailed or prolonged discussion with family members regarding seriously ill patient, lengthy communication necessary to coordinate complex services of several different health professionals working on different aspects of the total patient care plan)
Prolonged Physician Service (99354-99356)
direct patient contact in the Office setting
direct patient contact in the Inpatiaent setting
Prolonged Physician Service with Direct (Face-to-Face) Patient Contact (99354-99357)
Codes 99354-99357 are used when a physician provides prolonged service involving direct (face-to-face) patient contact that is beyond the usual service in either the inpatient or outpatient setting. This service is reported in addition to other physician service, including evaluation and management services at any level. Appropriate codes should be selected for supplies provided or procedures performed in the care of the patient during this period.
Codes 99354-99357 are used to report the total duration of face-to-face time spent by a physician on a given date providing prolonged service, even if the time spent by the physician on that date is not continuous.
Code 99354 or 99356 is used to report the first hour of prolonged service on a given date, depending on the place of service.
Either code also may be used to report a total duration of prolonged service of 30-60 minutes on a given date. Either code should be used only once per date, even if the time spent by the physician is not continuous on that date. Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the evaluation and management codes.
Code 99355 or 99357 is used to report each additional 30 minutes beyond the first hour, depending on the place of service. Either code may also be used to report the final 15-30 minutes of prolonged service on a given date. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.
The following examples illustrate the correct reporting of prolonged physician service with direct patient contact in the office setting:
Total Duration of Prolonged Services Code(s)
less than 30 minutes (less than 1/2 hour) Not reported separately
30-74 minutes (1/2 hr. - 1 hr. 14 min.) 99354 X 1
75-104 (1 hr. 15 min. - 1 hr. 44 min.) 99354 X 1 AND 99355 X 1
105-134 minutes (1 hr. 45 min. - 2 hr. 14 min.) 99354 X 1 AND 99355 X 2
135-164 minutes (2 hr. 15 min. - 2 hr. 44 min.) 99354 X 1 AND 99355 X 3
165-194 minutes (2 hr. 45 min. - 3 hr. 14 min.) 99354 X 1 AND 99355 X 4
99354 Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (eg, prolonged care and treatment of an acute asthmatic patient in an outpatient setting); first hour
99355 Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient contact beyond the usual service (eg, prolonged care and treatment of an acute asthmatic patient in an outpatient setting); each additional 30 minutes
99356 Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond the usual service (eg, maternal fetal monitoring for high risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient); first hour
99357 Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond the usual service (eg, maternal fetal monitoring for high risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient); each additional 30 minutes
Prolonged Physician Service Without Direct (Face-To-Face) Patient Contact (99358-99359)
Codes 99358 and 99359 are used when a physician provides prolonged service not involving direct (face-to-face) care that is beyond the usual service in either the inpatient or outpatient setting.
This service is to be reported in addition to other physician service, including evaluation and management service at any level.
Codes 99358 and 99359 are used to report the total duration of non-face-to-face time spent by a physician on a given date providing prolonged service, even if the time spent by the physician on that date is not continuous. Code 99358 is used to report the first hour of prolonged service on given date regardless of the place of service.
It may also be used to report a total duration of prolonged service of 30-60 minutes on a given date. It should be used only once per date even if the time spent by the physician is not continuous on that date.
Prolonged service of less than 30 minutes total duration on a given date is not separately reported.
Code 99359 is used to report each additional 30 minutes beyond the first hour regardless of the place of service. It may also be used to report the final 15-30 minutes of prolonged service on a given date.
Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.
99358 Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, communication with other professionals and/or the patient/family); first hour
99359 Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, communication with other professionals and/or the patient/family); each additional 30 minutes
(To report telephone calls, see 99371-99373)
Physician standby sevice (99360 1.62rvu)
Code 99360 is used to report physician standby service that is requested by another physician and that involves prolonged physician attendance without direct (face-to-face) patient contact. The physician may not be providing care or services to other patients during this period. This code is not used to report time spent proctoring another physician. It is also not used if the period of standby ends with the performance of a procedure subject to a "surgical package" by the physician who was on standby.
Code 99360 is used to report the total duration of time spent by a physician on a given date on standby. Standby service of less than 30 minutes total duration on a given date is not reported separately.
Second and subsequent periods of standby beyond the first 30 minutes may be reported only if a full 30 minutes of standby was provided for each unit of service reported.
99360 Physician standby service, requiring prolonged physician attendance, each 30 minutes (eg, operative standby, standby for frozen section, for cesarean/high risk delivery, for monitoring EEG)
(99360 may be reported in addition to 99431, 99440 as appropriate)
(99360 may not be reported in addition to 99436)
Follow-up Inpatient Consultations (99261-99263) Established Patient
Follow-up consultations are visits to complete the initial consultation OR subsequent consultative visits requested by the attending physician.
A follow-up consultation includes monitoring progress, recommending management modifications or advising on a new plan of care in response to changes in the patient's status.
If the physician consultant has initiated treatment at the initial consultation, and participates thereafter in the patient's management, the codes for subsequent hospital care should be used (99231-99233).
The following codes are used to report follow-up consultations provided to hospital inpatients or nursing facility residents only. For consultative services provided in other settings, the codes for office or other outpatient consultations should be reported (99241-99245).
99261 Follow-up inpatient consultation for an established patient, which requires at least two of these three key components:
• a problem focused interval history;
• a problem focused examination;
• medical decision making that is straightforward or of low complexity.
Counseling and/or coordination of care with other providers or agencies are provided consistent with nature of the problem(s) and the patient's and/or family's needs.
Usually, the patient is stable, recovering or improving. Physicians typically spend 10 minutes at the bedside and on the patient's hospital floor or unit.
Examples
Follow-up inpatient consultation with 35-year-old female with pulmonary embolism post-op caesarian section, now stable, for assessment of response to anticoagulation and recommended adjustment of heparin dose. (Pulmonary Medicine)
Follow-up inpatient consultation for 74-year-old male whose postoperative facial paralysis after a cholecystectomy is now resolving. (Neurology)
Follow-up inpatient consultation with 67-year-old female, established patient for review of diagnostic studies ordered at time of first contact. (Internal Medicine)
Follow-up inpatient consultation for 78-year-old female nursing home resident for evaluation of medical management of pruritis ani. (General Surgery/Colon & Rectal Surgery)
Follow-up inpatient consultation for a 36-year-old female 2 days after spontaneous passage of 3mm stone.(Urology)
Follow-up inpatient consultation for a 94-year-old male nursing home resident for re-evaluation of hemorrhoids following conservative therapy. (Colon & Rectal Surgery/General Surgery/Geriatrics)
Follow-up inpatient consultation for a 50-year-old male, asymptomatic with borderline ECG abnormality, needs preoperative opinion after a thallium exercise perfusion scan. (Cardiology)
99262 Follow-up inpatient consultation for an established patient which requires at least two of these three key components:
• an expanded problem focused interval history;
• an expanded problem focused examination;
• medical decision making of moderate complexity.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 20 minutes at the bedside and on the patient's hospital floor or unit.
Examples
Follow-up inpatient consultation with 72-year-old female, established patient with bullous pemphigoid on combined oral therapy steroids and immunosuppressive to evaluate progress of cutaneous care orders and adjustment of oral/parenteral therapy dosages. (Dermatology)
Follow-up inpatient consultation for a 71-year-old male who has developed a maculopapular skin rash while on antibiotics that you recommended for an uncomplicated pneumonia. (Infectious Disease)
Follow-up inpatient consultation with 68-year-old, incapacitated male, with spinal stenosis and failure to respond to bed rest, analgesics, and PT. (Neurosurgery)
Follow-up inpatient consultation with 51-year-old male, for evaluation and determination of the etiology of postoperative hyponatremia following TURP. (Family Medicine)
Follow-up inpatient consultation for reevaluation of a stroke patient, and development of plan for initial rehabilitation services. (Neurology)
Follow-up inpatient consultation with 45-year-old male, established patient for discussion of CT scan which demonstrates a cavernous hemangioma. (Ophthalmology)
Follow-up inpatient consultation for an asymptomatic 35-year-old Type I diabetic patient with hyperkalemic hyperchloremia acidosis, to review lab results. (Nephrology)
Follow-up inpatient consultation for an elderly male with a perioperative myocardial infarction requiring adjustment of vasoactive medications. (Anesthesiology)
99263 Follow-up inpatient consultation for an established patient which requires at least two of these three key components:
• a detailed interval history;
• a detailed examination;
• medical decision making of high complexity.
Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 30 minutes at the bedside and on the patient's hospital floor or unit.
Examples
Follow-up inpatient consultation with 72-year-old male established patient admitted for management of alcohol withdrawal, now confused and febrile. (Addiction Medicine)
Follow-up inpatient consultation for an HIV-positive patient with an increasing fever following ten days of antibiotic therapy for pneumocystis carinii pneumonia. (Infectious Disease)
Follow-up inpatient consultation with 58-year-old diabetic female, with bacterial endocarditis, continued fever after 2 weeks of intravenous antibiotic therapy, and new onset ventricular ectopia. (Cardiology)
Follow-up inpatient consultation for a 90-year-old female with urinary incontinence who has a complicated medical history requiring reassessment of multiple medical problems, recommendations for placement, further recommendation for management of incontinence and reevaluation of cognitive status because of competency issues.(Geriatrics/Psychiatry)
Follow-up inpatient consultation for 42-year-old male with persistent gastrointestinal bleeding, etiology undetermined, not responding to conservative therapy of transfusions. (General Surgery/Colon & Rectal Surgery)
Follow-up inpatient consultation for a 62-year-old female with steroid-dependent asthma, diabetes mellitus, thyrotoxicosis, abdominal pain and possible vasculitis. (Rheumatology)
Follow-up inpatient consultation for a 62-year-old male, status post-op acute small bowel obstruction; now with acute renal failure.(Family Medicine)