Basics of CPT code 80503, 80504, 80505 & 80506
Code selection can be based on time or level of complexity per medical decision making. Medical decision making describes CPT code 80503 as low in number and complexity of problems, amount and/or complexity of data to be reviewed, and risk of complications and/or morbidity of patient management. For CPT code 80504, 80505 & 80506 reporting follows similar coding guidelines.
The AMA’s Society Relative Value Scale Update Committee (RUC) recommended restructuring the code set based on levels of medical decision making, with options for reporting limited, moderately complex, highly complex, and prolonged pathology clinical consultation services. Providers will make their code selection based on the total time spent on consultation services on the date of the consultation or the level of medical decision making (MDM) required to complete the service.
The consultant must document the total time personally spent performing the consultation in the medical record to support the service(s) rendered. The calculated time should not include activities performed by clinical staff.
Per the new Pathology Clinical Consultation guidelines in the CPT 2022 code set, 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, including the time spent in activities that require the consultant. It does not include the time spent in activities normally performed by clinical staff.
Consultant time includes the following activities, when performed:
- reviewing available medical history, including presenting complaint, signs and symptoms, personal and family history;
- reviewing test results;
- reviewing all relevant past and current laboratory, pathology, and clinical findings;
- arriving at a tentative conclusion or differential diagnosis;
- comparing findings 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 QHPs (not separately reported);
- counseling and educating the physician or other QHP; and
- documenting the clinical consultation report in the electronic or other health record.
Read also: Coding Guidelines for Modifier 25 and 27
Description of CPT code 80503, 80504, 80505 & 80506
80503 Pathology clinical consultation; for a clinical problem, with limited review of patient’s history and medical records and straightforward medical decision making When using time for code selection, 5-20 minutes of total time is spent on the date of the consultation. (For consultations involving the examination and evaluation of the patient, see 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255)
80504 for a moderately complex clinical problem, with review of patient’s history and medical records and moderate level of medical decision making When using time for code selection, 21-40 minutes of total time is spent on the date of the consultation. 80505 for a highly complex clinical problem, with comprehensive review of patient’s history and medical records and high level of medical decision making When using time for code selection, 41-60 minutes of total time is spent on the date of the consultation. 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 health care 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). CPT Code 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 Code 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 Code 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 code 80506 is reported for 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.
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