CPT Codes

Information needed from residents when they submit autopsy, FNA or bone marrow data:

1. Resident Role: Either Primary or Secondary
   Primary – if you have the substantial responsibility during the procedure
   Secondary – if you had a primarily assisting role
2. Procedure Date
3. CPT Code*

*CPT CODES AVAILABLE FOR PATHOLOGY

AUTOPSY CODES

Give the appropriate code for non-forensic or forensic autopsy when you were actively involved (in either primary or secondary role) in each of the following components of a complete autopsy. Give:

• Review of medical history and circumstances of death
• External examination of the body
• Gross dissection
• Review of microscopic and laboratory findings
• Preparation of written descriptions of the gross and microscopic findings
• Development of an opinion regarding the cause of death
• Review of the autopsy report with a member of the teaching staff

Note: You may give a code for autopsies in which you were not involved in all seven of the above components using the appropriate code for gross examination only or limited autopsy.

BONE MARROW CODES

Enter the appropriate code when you perform a bone marrow aspiration or a bone marrow biopsy.

Note: You may give a code for the interpretation of a biopsy or aspirate, even if you did not perform the procedure.

FNA CODES

Give the appropriate code when you perform a fine needle aspiration.

OTHER CODES:

You may give any valid CPT code. For example, you may keep track of consultations, clinical pathology tests, identification of microorganisms, special stains, or surgical specimens examined. Tracking your experience in these areas, however, is not required.