When & How to Use Changed Clinical Laboratory Consult Codes

Procedural codes for clinical laboratory consults have existed for quite some time. Their utilization has frequently raised concerns for compliance due to a lack of clarity regarding when they’re appropriate to report for reimbursement. One challenge is that these codes are only related to clinical laboratory services and must be differentiated from anatomic pathology services.

Criteria for Reporting

According to Chapter 12 of the Medicare Claims Processing Manual, clinical consultations are paid under the physician fee schedule only if they:

• Are requested by the patient’s attending physician;
• Relate to a test result that lies outside the clinically significant normal or expected range in view of the patient’s condition;
• Result in a written narrative report included in the patient’s medical record; and
• Require the exercise of medical judgment by the consultant physician.

Clinical consultations are professional component services only; in other words, there’s no technical component (TC) service.

Routine conversations between a laboratory director and attending physician about test orders or results don’t qualify as consultations unless all four of the above requirements are met.

Laboratory personnel, including the director, may from time to time contact or be contacted by attending physicians to report test results or suggest additional testing. These contacts don’t constitute clinical consultations. However, if in the course of such a contact, the attending physician requests a consultation from the pathologist, it’s paid under the fee schedule, provided that the consultation meets the other criteria and is properly documented.

The Old Consult Codes

Until January 1, 2022, the clinical consultation codes were 80500 and 80502:

Previous Consult Codes

Code	Description
80500	Clinical pathology consultation; limited, without review of patient's history and medical records
80502	Clinical pathology consultation; comprehensive, for a complex diagnostic problem, with review of patient's history and medical records

The New Consult Codes

The above codes are no longer active and thus not operative for 2022. The good news is that the codes have been replaced with new codes that are now effective and still allow consult services to be reimbursed. Note: There are two new pages in Current Procedural Terminology (CPT) devoted to the required elements of each code. In general:

CPT 80503 reports a consultation requiring a limited review of the patient’s history and medical records. Medical decision making is straightforward; five to 20 minutes are typically spent on the date of consultation.

CPT 80504 reports a consultation for a moderately complex problem that requires a review of the patient’s history and medical records, moderate medical decision making, and approximately 21 to 40 minutes of total time spent on the date of consultation.

CPT 80505 reports a consultation for a highly complex problem requiring a comprehensive review of the patient’s history and medical records, a high level of medical decision making, and 41 to 60 minutes of total time spent on the date of consultation.

CPT 80506 reports prolonged services; this code is reported in addition to the code for the primary pathology consultation and is reported once for each additional 30 minutes.

New Consult Codes

Code	Description
80503	Pathology clinical consultation; for a clinical problem with limited review of patient's history and medical records and straightforward medical decision making. 5-20 minutes of total time is spent on the day of the consultation
80504	Pathology clinical consultation; for a moderately complex clinical problem with review of patient's history and medical records and moderate level of medical decision making. 21-40 minutes of total time is spent on the day of the consultation
80505	Pathology clinical consultation; for a highly complex clinical problem with comprehensive review of patient's history and medical records and high level of medical decision making. 41-60 minutes of total time is spent on the day of the consultation
80506	Pathology clinical consultation; for a prolonged service, each additional 30 minutes (list separately in addition to code for primary procedure)

AMA Introduction in CPT

CPT indicates that a clinical pathology consultation is a service performed by a physician (pathologist) in response to a written, electronic, face-to-face, or phone request from another physician/qualified healthcare professional who may be located at the same facility or another facility/institution.

The consultation entails clinical assessment, evaluation of pathology or laboratory results or other pertinent clinical or diagnostic information such as operative/procedure notes or radiology findings that require additional medical interpretive judgment, and includes a written report.

A clinical pathology consultation may also be provided by a pathologist when directed by state or federal regulation, such as Clinical Laboratory Improvement Amendments (CLIA).

The pathology clinical consultation services (80503, 80504, 80505, 80506) may be reported when the following criteria are met:

• The pathologist renders a pathology clinical consultation at the request of a physician or other qualified healthcare professional at the same or another institution
• The pathology clinical consultation request is related to pathology and laboratory findings or other relevant clinical or diagnostic information (e.g., radiology findings or operative/procedural notes) that require additional medical interpretive judgment.

AMA Instructions for Code Selection

Selection of the appropriate level of pathology clinical consultation services may be based on either the total time for pathology clinical consultation services performed on the date of consultation or the level of medical decision making as defined for each service. Here’s a quick look at these criteria:

Time

Time alone may be used to select the appropriate code level for the pathology clinical consultation services codes (i.e., 80503, 80504, 80505). When used to select the appropriate level for pathology clinical consultation codes, time is defined by the service descriptions. When prolonged service time occurs, add-on code 80506 may be reported. The appropriate time should be documented in the medical record when it is used as the basis for code selection.

Total time on the date of the consultation (pathology clinical consultation services): For coding purposes, time for these services is the total time on the date of the consultation. It includes time personally spent by the consultant on the day of the consultation (includes time in activities that require the consultant and does not include time in activities normally performed by clinical staff).

Consultant time includes the following activities, when performed:

• Review of available medical history, including presenting complaint, signs and symptoms, personal and family history
• Review of test results
• Review of all relevant past and current laboratory, pathology, and clinical findings
• Arriving at a tentative conclusion/differential diagnosis
• Comparing against previous study reports, including radiographic reports, images as applicable, and results of other clinical testing
• Ordering or recommending additional or follow-up testing
• Referring and communicating with other healthcare professionals (not separately reported)
• Counseling and educating the clinician or other qualified health care professional
• Documenting the clinical consultation report in the electronic or other health record

Medical Decision Making (MDM)

Elements of medical decision making include:

• Level of MDM (Based on 2 out of 3 elements of MDM)
• Number and complexity of problems addressed
• Amount and/or complexity of data to be reviewed and analyzed (*Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 described below)
• Risk of complications and/or morbidity or mortality of patient management

CPT 80503 identifies a low level of MDM, low number of problems and complexity (1 or 2), limited amount and complexity of data, and low risk of morbidity.

CPT 80504 entails a moderate level of MDM, moderate number of problems and complexity (3 or 4), moderate amount and complexity of data, and moderate risk of morbidity.

CPT 80505 entails a high level of MDM, high number of problems and complexity (5 or more), extensive amount and complexity of data, and high risk of morbidity.

The two pages in CPT provide more detail for criteria related to number and complexity of problems addressed and amount and/or complexity of data to be reviewed and analyzed.

Example: CPT 80503 indicates:

Number and Complexity of Problems Addressed

Low

• 1 to 2 laboratory or pathology findings or

• 2 or more self-limited problems.

Amount and/or Complexity of Data to be Reviewed and Analyzed

Limited (must meet requirements of at least 1 of 2 categories identified):

Category 1: Tests and documents.

• Any combination of two from the following:

 Review of prior note(s) from each unique source
 Review of the result(s) of each unique test
 Ordering or recommending additional or follow-up testing; or

Category 2: Assessment requiring an independent historian(s)

(For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high)

CPT 80504 and 80505 have separate requirements. Having the two pages from CPT available for reference while performing and documenting the consult is recommended. There may be merit for a template that documents the level identified and reported.

Other Instructions

Other key pointers:

• Use 80506 in conjunction with 80505

• Don’t report with 88321, 88323, 88325

• Prolonged consultation time less than 15 additional minutes isn’t reported separately.

While these coding changes have added complications due to detailed requirements, clarity is provided.

Reimbursement

Let’s compare reimbursement last year for the deleted codes and this year for new codes using the Medicare Physician Fee schedule.

CPT	MPFS 21	MPFS 22
80500	$19 estimate
80502	$71 “
80503		$23 estimate
80504		$50 “
80505		$90 “
80506		$41 “

The welcome news is that the new codes have a more favorable payment; this may counterbalance the increase in coding complexity.

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Diana W. Voorhees, M.A., CLS, MT, SH, CLCP, CPCO, is principal in DV & Associates, Inc., Salt Lake City, UT, which makes no representation, guarantee or warranty, expressed or implied, that the information provided is free of error, and will bear no responsibility or liability for results or consequences of its use.