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March 14, 2013

CPT Code 88305: Results of Progressive Corrective Action (PCA)

CPT code 88305: Level IV-Surgical pathology and microscopic examination

CGS conducted probe reviews on providers that submitted claims for CPT code 88305; providers were selected for these reviews based on their allowed services and charges. The overall error rate for Kentucky exceeded 21%, and the overall Ohio error rate exceeded 56.39%.

Based on our review of 200 claims, we identified the following issues.

  • The documentation did not support CPT code 88305 (a different surgical pathology code should have been submitted based on these records)
  • No documentation was present to support the order/intent to order

In our review of documentation, we found that while a signed pathology report was present, documentation of the order was missing. According to Medicare guidelines, either a signed order from the treating physician or progress notes documenting his/her intent to order must be present.

CGS has provided education to providers that were impacted, and we have begun the process of collecting any identified overpayments.

For more information on documentation requirements, please refer to:

Reviewed: 12.15.22


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