“CPT copyright 2016 American Medical Association. All rights reserved.

CPT is a registered trademark of the American Medical Association.”

 Current Procedural Terminology (CPT®) coding is part of the everyday routine in the surgical pathology laboratory as a billing numeric formalization of services rendered in the laboratory. Outside this goal the CPT code does not have any meaning. However, the use of the CPT code set is part of the Health Insurance Portability and Accountability Act (HIIPAA) law (1996). One of the clauses of the law is that neither the laboratory nor the pathologist can be paid for services unless CPT codes are reported on the claim.

This website presents guidance predominately for initial CPT coding during accession and grossing in the surgical pathology laboratory, as part of pre-analytical phase of specimen processing (www.grossing-technology.com).   Most laboratories assign a tentative CPT code to each specimen at time of accession with the code then being validated, or changed if indicated, after the pathologist has conducted the microscopic examination.The initial versus final CPT coding processes are explained in detail at the article Introduction to the Surgical Pathology CPT CookBook” on this website.

The materials provide detailed explanation of official American Medical Association (AMA) CPT manual’s provisions related to the surgical pathology laboratory practice. Divided by subspecialties, there are suggestions of coding some entries which are not mentioned in the manual. The suggestions reflect the principles of the AMA’s CPT coding  manual by facilitating navigation among numerous terms which are used in clinical practice. The official coding descriptors are illustrated by clinical case scenarios.

Some specific coding topics, such as add-ons, modifiers, intraoperative consultations, outside consultations, gross only, and others, are discussed. They often are a source of confusion.

The website is similar to a cookbook presenting examples and case scenarios of difficult and controversial coding situations. Although the cookbook comparison should not be taken too literally, practitioners benefit from a guide in which instructions and taxonomy are presented as ingredients for “recipes” to create “the dish”, or the right code selection. As in many cookbooks, some details are omitted for the sake of the succinct presentation.

This ”CookBook” with a capitalized B tends toward being a handbook or, better, a computer notebook. It is not so remote the time when instructional educational tablets like an iPad will be a routine part of the stationery at the workplace.The Internet education ought to include open access websites for unlimited public consumption. This is the future of the development in every professional group. The success of social media confirms the notion of a free intellectual interchange.

Accession staff, histotechnologists, grossing technologists, and pathologists’ assistants are the targeted audience of this website, but pathology residents and pathologist might be also interested. These materials can also attract the attention of professional coders and billing managers to the clinical side of coding.

The “CookBook” is not a substitute for the Pathology Service Coding Handbook by Dennis Padget. This fundamental comprehensive guide had been published for many years by DLPadget Enterprises, Inc. but  is now maintained by American Pathology Foundation, which recently acquired the Handbook. The Handbook was the trigger and the background for the development of the “CookBook.”

Changes in CPT coding manuals are constant. The “CookBook” will remain as a framework for adding some new developments, which are infrequent in surgical pathology.

The website’s materials were presented initially on the “Grossing Technology in Surgical Pathologywebsite (grossing-technology.com), where they remain as part of the initial stage of grossing technology. According to the daily statistics, approximately 20-25%% of the views are related to CPT coding. Hopefully, the separate CPT coding website, which has “inherited” the “Grossing Technology in Surgical Pathology” website’s CPT section, will serve additional visitors interested in the clinical aspects of coding in surgical pathology.

The recently added “Odds & Ends” section seems at first glance to be irrelevant to potential visitor’s professional interests, but it might be useful and perhaps interesting. My revelation regarding a tax-free IRA withdrawal can draw attention, especially during the tax seasons. My point is, however, that the ”tax season” ought to be extended via out-of-the-box thinking over the entire year.

Questions and comments would be appreciated as a platform for discussion. In the end of the day, a professional thoughtful discourse is the main purpose of maintaining the website.


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.

Copyright © 2015 by Izak B. Dimenstein  All rights reserved






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