Pathology and Laboratory Coding
Pathology and Lab Basics
Distinguish clinical laboratory tests from surgical pathology. Clinical lab codes are often organized by method (e.g., immunoassay, chromatography) and by analyte. Surgical pathology codes depend on specimen type, number of specimens, and level of examination (gross vs. microscopic).
Concepts You Must Know
- Specimen handling: each separately identified specimen may be coded separately.
- Frozen section vs. permanent section.
- Consultation vs. interpretation.
- Organ/disease panels and when they are appropriate.
- CLIA categorization and waived vs. moderate/high complexity testing.
Traps
- Counting a single specimen multiple times because multiple blocks were prepared.
- Using a panel code when only one component was performed.
- Confusing clinical lab method codes with pathology interpretation codes.
- Missing the distinction between screening and diagnostic lab testing.
Rule of Thumb
For surgical pathology, count separately identified specimens, not slides or blocks. For clinical lab, match the analyte and method to the code.
Worked Example
A single tissue specimen is processed into multiple blocks and slides. Report one surgical pathology code for that specimen, not one per block. If a second, separately identified specimen is submitted, it may be coded separately.