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Official Description

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

When using time for code selection, 21-40 minutes of total time is spent on the date of the consultation.

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

A clinical pathology consultation, represented by CPT® Code 80504, is a specialized service provided by a pathologist aimed at addressing moderately complex clinical problems. This consultation involves a thorough review of the patient's history and medical records, alongside a moderate level of medical decision-making. The pathologist is tasked with interpreting one or more pathology or laboratory test results, as well as providing additional medical judgment on relevant clinical or diagnostic information. Such consultations are typically requested by a physician or another qualified healthcare professional when there is a need for further evaluation of test results, radiology findings, operative notes, or other clinical data that may fall outside expected parameters or require deeper medical interpretation. The pathologist's role is crucial in these scenarios, as they synthesize the information available to offer insights that can guide further patient management. At the conclusion of the consultation, the pathologist generates a written report detailing their findings and recommendations. The time spent on this consultation ranges from 21 to 40 minutes, which is a key factor in determining the appropriate coding for the service. This structured approach ensures that the complexities of the patient's condition are adequately addressed, facilitating informed decision-making in their ongoing care.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The clinical pathology consultation represented by CPT® Code 80504 is indicated for situations involving moderately complex clinical problems. These may include, but are not limited to, the following:

  • Moderately Complex Diagnostic Issues The consultation is appropriate when a moderately complex diagnostic problem has been identified, necessitating further evaluation and interpretation of pathology or laboratory test results.
  • Review of Abnormal Test Results The service is indicated when there are pathology or lab test results that fall outside of expected ranges, requiring additional medical interpretation.
  • Additional Medical Judgment The consultation may be requested to provide further medical judgment on relevant clinical or diagnostic information that is critical for patient management.
  • Comprehensive Patient History Review The need for a thorough review of the patient's medical history and records is a key indication for this consultation, ensuring that all relevant information is considered.

2. Procedure

The procedure for a clinical pathology consultation under CPT® Code 80504 involves several key steps that ensure a comprehensive evaluation of the patient's condition:

  • Step 1: Request for Consultation The process begins with a formal request for consultation made by a physician or qualified healthcare professional. This request typically arises when there is a need for further evaluation of pathology or laboratory test results, or when additional medical interpretation is required for clinical information.
  • Step 2: Review of Patient's History Upon receiving the consultation request, the pathologist conducts a detailed review of the patient's medical history and all available medical records. This step is crucial as it provides context and background that inform the pathologist's evaluation.
  • Step 3: Evaluation of Test Results The pathologist then evaluates the relevant pathology or laboratory test results. This evaluation may involve comparing the results against expected ranges and identifying any abnormalities that may require further investigation.
  • Step 4: Medical Decision Making Based on the review of the patient's history and test results, the pathologist engages in moderate-level medical decision-making. This may involve determining the significance of the findings and considering potential implications for the patient's diagnosis and treatment.
  • Step 5: Documentation and Reporting Finally, the pathologist compiles their findings and recommendations into a written report. This report serves as a formal documentation of the consultation and is provided to the requesting physician or healthcare professional for further action.

3. Post-Procedure

After the clinical pathology consultation is completed, the pathologist's written report is delivered to the requesting physician or healthcare professional. This report includes the findings from the consultation and any recommendations for further action or management of the patient's condition. The total time spent on the consultation, which ranges from 21 to 40 minutes, is an important factor for coding purposes. If additional time is required beyond the initial consultation, CPT® Code 80506 should be reported for each additional 30 minutes spent on prolonged consultation services. It is essential for the requesting physician to review the report thoroughly to integrate the pathologist's insights into the patient's ongoing care plan.

Short Descr PATH CLIN CONSLTJ MOD 21-40
Medium Descr PATHOLOGY CLINICAL CONSULTATION MOD MDM 21-40MIN
Long Descr 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 When using time for code selection, 21-40 minutes of total time is spent on the date of the consultation.
Status Code Active Code
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator STV-Packaged Codes
Berenson-Eggers TOS (BETOS) none
MUE 1
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
GC This service has been performed in part by a resident under the direction of a teaching physician
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
AJ Clinical social worker
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
CR Catastrophe/disaster related
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
X5 Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
Action
Notes
2022-01-01 Added Code added
Code
Description
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