Pathologists often provide extensive consultative services to other physicians beyond establishing a diagnosis or providing laboratory test results, but they are typically not financially compensated for these services. Another relatively new role for pathologists in the United States is as a consultant who works directly with patients.
To review how pathologists provide detailed consultation to other physicians, how pathologists can be financially compensated for this critical service, and how pathologists are increasingly serving as a consultant directly with patients and their families.
Sources were peer-reviewed medical literature and the author's personal experience.
In recognition of the extensive consultative services provided by both clinical and anatomic pathologists to other physicians, procedural codes recently approved and valued by the Centers for Medicare & Medicaid Services now provide a compensation mechanism for these services for government-insured and potentially privately insured patients. Pathologists are also increasingly providing consultative services directly to patients, resulting in significant patient satisfaction and providing important support for patients and their physicians.
Pathologists' clinical roles are often thought to involve 2 main functions: (1) morphology-based diagnosis on surgical, cytology, and autopsy specimens, and (2) oversight and direction of the clinical laboratory. An intrinsic part of both functions, but one often less recognized, is to provide consultation to other physicians and health care providers in the management of their patients. For decades, pathologists have been referred to as the doctor's doctor, a term that alludes to this consultative role but still does not fully reflect the depth and breadth of consultative services provided by pathologists.
Sir William Osler, in a lecture before the Ontario Medical Society in 1909,1 captured well the role of pathologists in guiding the diagnosis and treatment of disease: “As is our pathology so is our practice; what the pathologist thinks today, the physician does tomorrow.” It has been estimated that 70% of medical decisions are based on clinical laboratory and/or pathology data,2 an impressive statistic but one that implies that the data themselves are all that is needed from the clinical laboratory or pathologist in the care of patients. How the data are applied in medical decision-making is clearly more important than simply having access to the data. The medical background of a pathologist as a physician and the years of residency and fellowship training received by pathologists in preparation for practice arguably make pathologists uniquely qualified to understand both the technical underpinnings of clinical laboratory test results and pathologic diagnoses and how best to apply these data to detect, fully characterize, and properly manage a patient's disease.
Pathologists are frequently sought out by other physicians and health care providers to help assimilate increasingly complex clinical laboratory data, detailed pathologic diagnoses, and other ancillary information important to disease classification and treatment.3 Yet this assistance freely provided by pathologists in essentially all practice settings is often done informally, as so-called curbside consults, and frequently without the preparation of a traditional written consultation report or the ability to be financially compensated for this service.
Starting several years ago, a way for pathologists to be compensated for this type of consultation for Medicare patients was provided by the Centers for Medicare & Medicaid Services (CMS). Using American Medical Association Current Procedural Terminology (CPT) codes 80500 and 80502, consultation by a pathologist that met certain requirements could result in a payment to the pathologist. These codes were designated for “clinical pathology consultation,” and as such were essentially never used for anatomic pathology–related consultation. For a variety of reasons, relatively few clinical pathologists billed using these codes, and Medicare claims data documented their infrequent usage. Starting in January 2022, the 2 existing consultation CPT codes were retired and 4 new codes (80503, 80504, 80505, and 80506) were introduced for pathologists to provide detailed consultation to other health care providers. These codes, for “pathology clinical consultation,” are structured in such a way that both clinical and anatomic pathologists can appropriately use them to provide consultation that requires medical judgment. Similar to the older clinical pathology consultation codes, use of these codes involves fulfillment of certain requirements, but their structure is significantly better suited to the way all pathologists, both clinical and anatomic, provide consultative services to other clinicians.
Another form of consultation by pathologists, provided directly to patients, was largely unknown in the United States until relatively recently. Although pathologists do interact directly with patients when performing certain procedures (eg, fine-needle aspiration, bone marrow specimen acquisition, apheresis oversight, etc), other direct interaction between pathologists and patients to discuss laboratory results and/or diagnoses has been uncommon. Not only has this type of consultation been infrequent, but until recently direct communication by pathologists with patients about their test results and/or diagnosis was not allowed in some jurisdictions. One such jurisdiction, New York State, in 2017 finally allowed this type of direct communication between pathologists and patients.4
As many patients have become more knowledgeable about their health status and laboratory test results and pathology reports have been increasingly available directly to patients through electronic portals, interest on the part of patients to seek information directly from pathologists has significantly increased. In response to this emerging trend, many pathologists are proactively seeking opportunities to directly engage with patients and their family members.5–7
In this review, new opportunities for pathologists to provide formal consultative services to other physicians and health care providers and the means to be compensated for this consultation will be discussed in detail. In addition, the expanding role of pathologists in providing direct consultation to patients will be illustrated and the impact of this direct patient interaction described. This will hopefully serve as a guide to pathologists as they increasingly take their place as valued consultants to fellow clinicians and trusted and sought-after resources for patients and their families.
CONSULTATION FOR OTHER PHYSICIANS AND HEALTH CARE PROVIDERS
The role of pathologists as consultants for other physicians and health care providers has been an intrinsic part of the clinical practice portfolio of both anatomic and clinical pathologists for decades. For anatomic pathologists, guidance provided to other clinicians in the care of their patients has typically been done in the context of a morphologic diagnosis rendered by the involved pathologist. In the clinical laboratory, clinical pathologists often provide advice to other health care providers in the selection of laboratory tests and interpretation of test results in the context of a specific patient's clinical status. Although these various consultative services are highly valued by other clinicians and often proactively requested by them in the care of their patients, they are traditionally requested and done informally, with no formal order and no written report or note provided by the pathologist.
As clinical laboratory testing has become more complex in recent years and molecular and other ancillary data have grown in importance in all diagnoses, including anatomic pathologic diagnoses, the need to involve pathologists in helping to guide testing, interpret complex test results, and apply molecular and other ancillary findings to establish complete and actionable diagnoses has grown proportionately. Although other physicians often have a good general understanding of how to use the clinical laboratory in the care of their patients, the combined technical and clinical insight of a pathologist is increasingly called upon to help rationalize and guide the often-complex laboratory workup of a patient in certain clinical settings. The evaluation and management (E/M) of a patient with a complex coagulation abnormality, the attempt to diagnose a difficult infectious disease, or the need to assess a patient with complicated toxicology laboratory findings frequently benefits from input by a pathologist who knows the proper use of the multiple assays pertinent to these clinical scenarios. In some settings, pathologists have formed “diagnostic management teams” to provide a framework to make consultation by pathologists to help solve specific clinical problems a routine occurrence.8 These diagnostic management teams have grown in popularity as an effective and efficient approach to diagnosis and management in patients with complex clinical problems, but they typically deal only with clinical laboratory workup and not with anatomic pathologic diagnoses.
The importance of proteomic and genomic data in establishing diagnoses in anatomic pathology and fully classifying neoplastic and nonneoplastic disorders has grown dramatically during the past decades. Although standardization of diagnostic criteria and reporting format has helped to bring a high degree of objectivity to these diagnoses, the need to understand and apply these criteria in the context of the clinical presentation of a patient and the use of medical judgment in finalizing a diagnosis and treatment plan often require the insight of a pathologist beyond simply establishing the basic diagnosis. Particularly as targeted therapies and immunotherapies have expanded in recent years, pathologists have increasingly been called upon to provide guidance to other clinicians in the use of these emerging therapies in specific clinical scenarios. This guidance often requires the pathologist to integrate gross and microscopic findings, imaging studies, immunohistochemical results, and a range of genomic and epigenomic data to fully characterize a neoplastic or nonneoplastic process. These data are increasingly from sources beyond the specimen on which the basic diagnosis is established.9
Retired CPT Codes for Clinical Pathology Consultation
Similar to consultation provided by other specialists and subspecialists, pathologists should be compensated appropriately for this contribution to clinical management. The old and now retired CPT codes for providing clinical pathology consultation (Table 1) were useful in describing the general service provided but were considered by many to be overly restrictive and not sufficiently granular in documenting the level of work involved. The fact that these codes were used infrequently and almost exclusively for clinical pathology services was a good indication that they were not structured properly for the way most pathologists provide clinical consultation and were not perceived as being appropriate for the type of consultation provided by anatomic pathologists.
Use of these codes required that multiple conditions be met: (1) The consultation is requested by the patient's attending physician. (2) The request relates to a test result that lies outside the clinically significant normal or expected range in view of the condition of the patient. (3) The consultation results in a written narrative report included in the patient's medical record. (4) The consultation requires the exercise of medical judgment by the consultant physician.
Of these conditions, the requirement that the request relate to a specific abnormal or unexpected test result was perhaps the most controversial and difficult to meet. Clinical pathologists are often asked to help guide the laboratory workup of a patient's clinical problem without reference to a specific abnormal test result, a service that typically involves both knowledge of the appropriate tests and medical judgment based on assessing the patient's overall clinical picture. Although anatomic pathologists' consultative services are commonly requested in the context of a diagnosis rendered by the anatomic pathologist, technically an “abnormal test result,” the interpretive services required to establish the diagnosis would already have resulted in the pathologist being compensated, thus disqualifying the additional consultation from further compensation.
New CPT Codes for Pathology Clinical Consultation
New pathology clinical consultation codes, first available in 2022, were created to more appropriately reflect the settings in which pathologists provide consultation and the work involved in performing this service. The CPT codes 80503, 80504, 80505, and 80506 (Table 2) are designed to capture the process of a pathologist assessing the totality of a patient's laboratory, anatomic, and/or ancillary data in the context of the patient's overall clinical status. Although the patient's laboratory test results and/or anatomic findings are almost certainly abnormal, the basis of the consultation is to address the patient's clinical problem and not simply the abnormal test result. This key point aligns much more closely with how other physicians provide consultative services.
Similar to other physician consultations that are coded using E/M CPT codes, the first 3 pathology consultation codes are rated based on either the time required to provide the service or the level of medical decision-making (MDM) involved. Consideration of the time and/or level of MDM was part of the process used by the CMS in determining the physician work relative value units for these codes (Table 2) and the compensation of the pathologist for these services. The fourth code (CPT 80506) is an add-on code used to reflect additional service time required to provide the full consultation, assessed in 30-minute increments and used in combination with CPT 80505, the most intense and time-consuming of the 3 basic codes.
Similar to the old codes, the new consultation codes also require that certain conditions be met.10 These include: (1) The consultation is requested by a physician or qualified health care professional at the same or another institution, indicated by a written or verbal order from the treating physician. (2) The request is in relation to pathology and laboratory findings or other relevant clinical or diagnostic information requiring additional medical interpretative judgment. (3) The consultation relates to an abnormal test result that requires medical judgment by a physician. (4) The consultation results in a written report documenting the consultation that appears in the patient's medical record.
The second and third of these conditions are intrinsic to how pathologists provide consultation and should be easy to fulfill. Importantly, the request for consultation is not restricted only to an abnormal pathology or laboratory finding but now includes any clinical or diagnostic information relevant to the patient's problem. The requirement of a written report parallels how other physicians report the findings of their consultations. The need for a written or verbal order from the patient's treating physician formally requesting the consultation is beyond how pathologist consultations are typically requested. This is similar to how consultations by other physicians are requested and, as such, should theoretically be easy to accomplish; however, this will almost certainly require a reset on the part of physicians needing a pathology consultation because these are traditionally requested informally. It will be incumbent upon pathologists to educate their clinician colleagues regarding this requirement and encourage them to generate a written order or make a verbal request whenever a substantive consultation is needed. When requested verbally, the request and the name of the requesting provider should be documented in the written consultation report. As was true for the old pathology consultation codes, the new codes require that an individual order be generated for each patient needing this type of consultation.10 A standing order will not suffice for this purpose. The use of these codes is not allowed for consultation as part of a pathology or laboratory service that has already included pathologist interpretation and that can be billed separately.10 As an example, a pathologist cannot bill separately for consultation when the medical judgment involved has already been applied as part of a basic interpretative service provided by the pathologist. This requires that the consultative service involves clinical assessment and medical judgment above and beyond basic and otherwise billable interpretative activities. The proper use of these codes will clearly require additional guidelines from the CMS as pathologists and the agency both gain experience with their use.
Similar to CPT codes for E/M services, the new pathology consultation codes may be rated based on the total time or level of MDM required to perform the consultation. When time is the basis of determining which code to use, this will require documentation of the time by the pathologist, most conveniently included in the written consultation report, which would then become part of the patient's medical record, similar to how other physicians document time in performing E/M services.11 Using the level of MDM to determine the appropriate consultation code is more complicated and based on the complexity of the patient's problem, extent of clinical review required by the pathologist, and/or the potential risk to the patient. Detailed guidelines for determining the MDM levels relevant to these codes are included in American Medical Association CPT 2022 publications.12
CONSULTATION DIRECTLY WITH PATIENTS
Unlike consultation provided by pathologists to other physicians, pathologists providing consultative and counseling services directly with patients regarding their laboratory test results and/or pathologic diagnosis is a relatively recent development in the United States. Although pathologists do provide some services directly to patients (eg, fine-needle aspiration, bone marrow specimen acquisition, apheresis oversight, etc), and can bill for E/M services as part of some of these direct encounters, pathologists have not traditionally discussed laboratory test results or diagnostic findings directly with patients or their families.
Rare examples of patients contacting pathologists for more information about a laboratory abnormality or a pathologic diagnosis have occurred over the years, but these were sufficiently uncommon that most pathologists would never receive such a request. In recent years, this has become significantly more common. The reasons for this are many, but the following 2 factors are likely the most important.
Patient Access to Health- and Disease-Related Information
Patients currently have much more extensive access to information about health and disease than in the past. Popular magazines, books, and broadcast media have increasingly presented health-related topics and raised the awareness of health and disease among the general public. Surpassing even those sources of information, the Internet and social media platforms have had a dramatic impact on access to health-related information. The average patient now has accessed 1 or more of these sources to try to understand laboratory test results and/or a pathologic diagnosis they have received. Their access to this health-related information often results in more questions than answers, leading many patients and even their family members to seek clarification from either the attending physician or, more recently, from the laboratory and/or the pathologist involved in their evaluation.
Patient Access to Their Own Health Records
Patients have increasingly had easy and rapid direct access to their laboratory test results and to pathology reports on their biopsy, resection, and other specimens. Although written reports have been available to patients for many years in certain circumstances, beginning in the early 2000s a movement began to give patients rapid electronic access to this information. This was part of a broad effort to make health care delivery more patient-centered and to involve the patient more directly in decision-making regarding their own care. Technologic advances and the dramatic increase in the availability of electronic devices have made this access increasingly easy to accomplish. At the same time, a proactive stance on the part of the federal government to accelerate this effort provided incentives and subsequently made this a requirement for health care institutions and providers. The HITECH Act of 2009 included specific provisions to increase the use of electronic health information systems by institutions and providers and to encourage easy access for patients to their own health records.13 This accelerated the development of so-called patient portals through which patients and their families can receive rapid electronic access to all of their records, including laboratory test results and pathology reports. Because certain laboratory results and pathologic diagnoses were considered highly sensitive, particularly those related to human immunodeficiency virus (HIV) infection status and malignant diagnoses, many health care organizations temporarily embargoed or otherwise delayed patients' electronic access to this information until the patient's attending physician received the result and had a chance to communicate with the patient. Even this delay has become unsustainable because certain health care and patient advocacy organizations advocated for and the federal government mandated immediate access to even sensitive information. The 21st Century Cures Act of 2021 includes requirements that all laboratory and pathology information be made immediately available to patients at no charge.14 Although exceptions may be made, the process required to establish and maintain exceptions is detailed and difficult to use.
As patients have gained dramatically more access to health-related information from many sources and now have immediate access to essentially all of their health records, interest on the part of patients and their family members to communicate directly with pathologists to discuss laboratory and pathologic findings has grown significantly. As a result, pathologists now much more commonly receive calls from patients seeking clarification and other information about their test or pathology results. Although as physicians, most pathologists are quite comfortable communicating with patients, a few have been reluctant to provide this service. In preparation for the increased likelihood of direct communication with patients, some pathology training programs have begun to give their trainees experience in this area.15 As this trend continues, the preparation of pathology trainees and practicing pathologists for direct communication and consultation with patients will be increasingly important.6
When pathologists communicate directly with a patient or their family members, it is very important that the patient's attending physician be informed of this communication, if possible before the communication takes place.5 Some physicians and other providers may be initially uncomfortable with this type of direct communication with their patients. Advance notification of the patient's attending physician allows the pathologist to reassure the physician of their desire to be helpful and not to interfere with their existing physician-patient relationship. In addition, this advance communication allows coordination of what the patient is being told about their laboratory and pathology findings and what these findings may mean for their management and/or prognosis.
The Patient-Pathologist Consultation Service
Beyond simply accepting requests from patients for information and/or direct communication, a growing number of pathologists are actively encouraging this type of direct consultation. Some pathologists have even established a formal patient-pathologist consultation service to encourage and provide a platform for direct consultation with patients and their family members (Figure 1).15 Some of these involve only the patient and the pathologist, whereas others may also include the patient's attending physician and/or other relevant providers in a group communication with the patient. One form of this type of joint patient consultation is the so-called virtual tumor board, with the patient, their family members, the pathologist, the oncologist, and other relevant providers meeting together and discussing the diagnosis and management of the patient's neoplasm.5
Example of a promotion for Dr Lija Joseph's community hospital–based patient-pathologist consultation service. Used with the permission of Lija Joseph, MD.
Example of a promotion for Dr Lija Joseph's community hospital–based patient-pathologist consultation service. Used with the permission of Lija Joseph, MD.
The mode and venue of the communication between patients and the pathologist may vary. Discussion of a pathologic diagnosis often includes reviewing microscopic findings with the patient. When done in person, a suitable space is needed with a multiheaded microscope and/or video monitor to project microscopic images. The most advanced of these consultation services have created a sophisticated space specially designed for meeting with the patient and their family members and reviewing morphologic and other findings (Figure 2). The nearly universal availability of video photomicrography and emergence of video conferencing platforms, such as Zoom (Zoom Video Communications, Inc; San Jose, California), Webex (Cisco Systems, Inc; San Jose, California), and many others, have made remote, virtual meetings a convenient and effective option. The virtual option is particularly useful in providing a comfortable means for a patient who may be in the immediate postoperative state or otherwise too ill to meet in person to benefit from this important service. It also allows family members who may be in a distant location to participate.
Patient-pathologist consultation room at Upstate Medical University in Syracuse, New York. Used with the permission of Rohin Mehta, MD, at Upstate Medical University.
Patient-pathologist consultation room at Upstate Medical University in Syracuse, New York. Used with the permission of Rohin Mehta, MD, at Upstate Medical University.
Impact of Patient-Pathologist Consultation
As direct patient-pathologist consultation has become increasingly common, the acceptability and impact of this type of direct communication with patients have begun to be studied and recognized. Although the increased frequency of patients reaching out directly to pathologists for more information clearly indicates acceptance by some patients, a more structured study of this practice is needed. A proposed patient-pathologist consultation program for cancer patients at an academic institution and affiliated local community cancer support group was studied recently.7 Of the patients surveyed in this study, 85% were interested (75% “definitely interested,” 10% “interested”) in meeting with a pathologist familiar with their diagnosis and seeing a microscopic slide of their tissue. The patients who expressed interest cited empowerment, demystification, and enhanced understanding as the major motivating factors for their interest. Similar results have been found in other studies involving pathologist consultation with cancer patients and often their family members, with approximately 90% to 100% of participating patients expressing strong satisfaction with the consultation.15–17 Although these studies may suffer from relatively small numbers of participants and at least some selection bias, based on the limited source of study participants and the inclusion of individuals who have already chosen to meet with their pathologist, the results nonetheless indicate a likely high level of acceptance on the part of cancer patients for direct consultation with a pathologist. Like other patient-centered communication, direct access on the part of a patient to a pathologist familiar with their diagnosis and/or laboratory abnormalities will not only increase the patient's understanding of their health status, but may also help the patient accept the need for additional testing, including detailed genetic and other molecular studies, and potentially lead to greater compliance with their treatment plan. Studies to show the long-term impact of this consultation on patient outcomes will take considerable time to complete, but should be pursued.
In addition to acceptance by patients, another very important stakeholder regarding this type of direct consultation is the patient's attending physician. Although some physicians may harbor concerns that their patient is communicating directly with a pathologist, in some cases without the attending physician's advance knowledge of or participation in the consultation session, many clinicians recognize the benefit to them and their patients from the information and reassurance provided by the pathologist. Although a large study of the impression of patients' attending physicians regarding direct patient-pathologist communication has yet to be done, anecdotal comments and small surveys have shown a generally positive reaction on the part of clinicians.7,15,17 In addition to providing patients with detailed information about their diagnosis or test results, some of which the attending physician may not be able to provide, clinicians also cited overall patient satisfaction as a positive aspect of patient-pathologist consultation. Further study of attending physicians' attitudes toward direct consultation by pathologists with their patients is clearly needed.
The level of interest among pathologists in providing direct patient consultation is likely to vary widely. Although interest appears to be growing in recent years, some pathologists will be hesitant to get involved in this additional service for patients. This activity is time-consuming and would clearly impact the existing workflow for pathologists and/or their departments. Other pathologists welcome the opportunity to interact directly with patients, in many ways reinforcing that these are their patients and they are a visible part of the clinical team providing care. The possibility of billing for this service may be an inducement for some pathologists. This type of service would technically qualify as E/M, and billing would require that the service comply with the detailed guidelines for E/M services,18 which are complex and include the need for a written report and proper documentation regarding the encounter for inclusion in the patient's health record. Remote, virtual consultation with a patient would also require that the service comply with any additional telemedicine billing guidelines.19 In the era of expanding value-based and other non–fee-for-service payments for medical services, direct consultation by pathologists with patients and their family members would clearly qualify as a value-added service, providing justification for institutional recognition and potential additional compensation for this added service.
Another important, albeit less obvious, potential benefit of direct patient-pathologist consultation is related to greater visibility of the role and value of pathologists in the eyes of patients, other physicians, and health care institutions and government agencies. Most patients and many physicians have little or no concept of what pathologists do or how they contribute to patient care, both for individual patients and patients at large. Broader knowledge of how pathologists function as physicians and clinical consultants will arguably make patients, other physicians, and health care institutions more likely to support pathologists' advocacy efforts for full recognition and fair payment for their services.
SUMMARY
Pathologists have served as clinical consultants to other physicians and health care providers since the beginning of pathology as a clinical specialty. Although this consultative role has traditionally been performed informally and often without recognition or compensation, pathologists have increasingly become a formal and more visible resource for other clinicians in the care of their patients. The growing complexity of clinical laboratory testing and pathologic diagnosis has dramatically expanded pathologists' role in helping guide other clinicians in the diagnosis, characterization, and management of disease. In recognition of this expanding role, clinical and anatomic pathologists now have properly structured CPT codes with which they can be compensated for this unique contribution to patient care. It is imperative that pathologists learn to use these codes correctly to ensure appropriate compensation for this critically important service.
Beyond consultation provided to other clinicians, in recent years pathologists have emerged as a direct resource for patients and their families, providing them with needed information, insight, and reassurance regarding the patient's clinical laboratory, pathologic, and other ancillary findings. From simple encounters to answer a patient's specific question to formal patient-pathologist consultation services, pathologists are now increasingly interacting directly with patients and their family members to help bridge the gap in their understanding of their clinical laboratory test results and/or pathologic diagnoses. No longer just the “doctor's doctor,” pathologists are now becoming more widely recognized as the patient's doctor, directly providing information and counseling important to patients' clinical management and well-being.