Tissue Examination Report - CDT Code Guide
Overview
CDT Code D0473 is used for the accession of tissue, involving gross and microscopic examination, and the preparation and transmission of a written report. This code is essential in oral pathology for diagnosing conditions through the analysis of architecturally intact tissue obtained via invasive procedures. Typically, this procedure involves the careful collection of tissue samples, which are then examined under a microscope to identify any pathological changes. The findings are compiled into a comprehensive report that aids in the diagnosis and treatment planning. This code is crucial in scenarios where a detailed tissue analysis is required to confirm or rule out specific oral health conditions.
When to Use This Code
- When a biopsy is performed to diagnose a suspicious lesion in the oral cavity.
- In cases where oral cancer is suspected and tissue analysis is necessary.
- For monitoring known oral pathologies that require periodic tissue examination.
- When a patient presents with unexplained oral symptoms that warrant further investigation.
- In the follow-up of previously treated oral conditions to assess treatment efficacy.
Documentation Requirements
- Detailed patient history and clinical findings leading to the tissue sampling.
- Description of the tissue sample, including size and location.
- Microscopic examination findings and interpretation.
- A comprehensive written report of the examination results.
- Documentation of the communication of results to the referring clinician.
- Proper coding and billing documentation for insurance claims.
Billing Considerations
When billing for D0473, it is important to ensure that the procedure is medically necessary and properly documented. Frequency limitations may apply, so verify with the patient's insurance provider. Common modifiers may include those that indicate the specific nature of the procedure or any special circumstances. Ensure that the procedure is covered under the patient's insurance plan to avoid unexpected out-of-pocket costs.
Related CDT Codes
Frequently Asked Questions
D0473 covers architecturally intact tissue samples obtained by invasive means, typically requiring a biopsy.
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