Tissue Examination - CDT Code Guide
Overview
CDT Code D0474 pertains to the accession of tissue for both gross and microscopic examination, including the assessment of surgical margins for the presence of disease. This procedure is crucial in diagnosing oral pathologies, as it involves the careful examination of architecturally intact tissue obtained through invasive means. The process includes preparing and transmitting a detailed written report, which is vital for determining the presence of disease and guiding further treatment. Typically, this code is used in scenarios where a biopsy or surgical excision has been performed, and the tissue needs to be evaluated for pathological conditions such as cancer or other diseases. The examination helps in understanding the extent of the disease and planning appropriate treatment strategies.
When to Use This Code
- When a biopsy of oral tissue is performed to check for cancerous cells.
- During surgical procedures where tissue margins need assessment for disease presence.
- In cases where there is a need to confirm a diagnosis of a suspected oral pathology.
- When monitoring the progression of a diagnosed oral disease.
- For evaluating tissue samples obtained from invasive dental surgeries.
Documentation Requirements
- Detailed clinical notes describing the reason for tissue examination.
- A copy of the patient's consent for the invasive procedure.
- A comprehensive written report of the gross and microscopic findings.
- Documentation of the surgical procedure and the tissue accession process.
- Clear identification of the tissue source and any relevant clinical history.
- Record of communication with the patient regarding the findings and next steps.
Billing Considerations
When billing for D0474, ensure that the procedure is justified by clinical necessity and documented thoroughly. Be aware of any frequency limitations imposed by insurance providers, as repeated examinations may require additional justification. Common modifiers may include those indicating the specific site of tissue collection or the nature of the surgical procedure. It's important to verify coverage with the patient's insurance provider, as some plans may have specific requirements or limitations for pathology services.
Related CDT Codes
Frequently Asked Questions
D0474 is used for architecturally intact tissue obtained through invasive means, such as biopsies or surgical excisions.
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