AI-assisted Pathology
Coding
Welcome to the world of AI-assisted pathology coding! In this
presentation, we will explore how artificial intelligence can help
medical coders analyze pathology reports and assign the most
appropriate ICD-10 diagnosis codes and CPT codes. Let's dive in
and discover the power of AI in healthcare!
Prompt Example:
• "I'm a medical coder reviewing this pathology report. Please
read the findings and impressions and recommend the most
appropriate ICD-10 diagnosis codes and CPT codes for this
specimen. Briefly explain your rationale for choosing those
codes based on what is documented.“
Pathology report: "Biopsy of lung tissue shows evidence of non-small cell
1 ICD-10 Code
Based on the findings, the appropriate ICD-
10 code for non-small cell lung carcinoma
is C34.90.
2 CPT Code
The CPT code for the biopsy of the lung is 31622.
3 Rationale
The documentation specifically mentions
"non-small cell lung carcinoma," which
informs the ICD-10 code selection, and
"biopsy of lung tissue" for the CPT code.
Prompt Example:
• "Act as an experienced pathology coder and analyze
this report. Provide your code recommendations by
listing the relevant ICD-10 and CPT codes. Write 1-2
sentences summarizing the key findings that support
your code choices."
• Pathology report: "Liver biopsy reveals chronic hepatitis C infection."
ICD-10 Code CPT Code
The ICD-10 code for chronic hepatitis C is B18.2.
The CPT code for the liver biopsy is 47000.
Rationale
The diagnosis of "chronic hepatitis C infection" guides the ICD-10
choice, and the procedure mentioned, "Liver biopsy," leads to the
CPT code.
Prompt Example:
• "Imagine you are a pathology coding specialist. Read this pathology
report and draft a short summary with: The ICD-10 codes you would
assign, The CPT codes you would use, Brief rationale for your code
• choices based
Pathology on the
report: pathologist's
"Excisional biopsyfindings."
of skin lesion on the arm shows basal cell carcinoma."
ICD-10 Codes CPT Code Rationale
I would assign The CPT code for The biopsy revealed
ICD-10 code the excisional "basal cell
C44.319 for basal biopsy of the skin carcinoma," which
cell carcinoma of lesion is 11600. provides the basis for
the skin of the the ICD-10 diagnosis,
unspecified part and the procedure
of the limb. "excisional biopsy of
• "I'm an entry-level pathology coder seeking guidance. Please
review this pathology report and explain which ICD-10 and CPT
codes you would assign. Point out the key terms and findings that
• justify the codes
Pathology report:you recommend."
"Fine needle aspiration of the thyroid reveals papillary carcinoma."
1 ICD-10 Code
I'd recommend the ICD-10 code C73 for malignant neoplasm of the thyroid gland.
2 CPT Code
The CPT code for fine needle aspiration of the thyroid is 10021.
3 Rationale
The term "papillary carcinoma" supports the ICD-10 code, and "fine needle
aspiration of the thyroid" justifies the CPT code selection.
Prompt: "Determine the correct
CPT code for the panel tests
described in the pathology
report."
• Example: Report: "Comprehensive tests on the blood specimen
included albumin, bilirubin-total, calcium, carbon dioxide,
chloride, creatinine, glucose, phosphatase, potassium, protein-
total, sodium, transferase, and urea nitrogen." Response: "This
description matches the Comprehensive Metabolic Panel. The
associated CPT code is 80053."
Prompt: "Identify if the tests
mentioned in the pathology report
are part of any panel and provide
the associated panel CPT code."
• Example: Report: "Tests were performed on glucose, calcium,
and albumin levels in the patient's blood." Response: "These
tests are part of the Basic Metabolic Panel. The corresponding
CPT code for this panel is 80048."
Prompt: "Based on the pathology
report, recommend the
appropriate CPT modifier for the
services rendered."
• Example: Report: "The cytopathology smears were solely
interpreted by our pathologist without any involvement in the
slide preparation." Response: "In this case, only the professional
component was performed. Use the modifier -26."
Prompt Example:
• "As an experienced pathology coder, provide the ICD-10 and CPT codes for this
report. Identify the portions of the pathologist's observations and impressions
• that supportreport:
Pathology your code assignments."
"Histopathological examination of the breast tissue
shows invasive ductal carcinoma."
ICD-10 Code CPT Code Rationale
The ICD-10 code that Let's say it's a biopsy, The phrase "invasive
fits the findings is so 19000 for needle ductal carcinoma" is
C50.919 for malignant biopsy of breast. the basis for the ICD-
neoplasm of 10 code, and the type
unspecified site of the of examination
unspecified female "Histopathological
breast. examination of the
The Power of AI in Pathology Coding
Efficiency Accuracy Consistency
AI streamlines the AI algorithms are trained AI ensures consistency in
pathology coding to accurately analyze code assignments,
process, reducing pathology reports and reducing errors and
manual effort and assign the most ensuring compliance
increasing productivity. appropriate codes. with coding guidelines.
The Future of Pathology Coding
1 Advanced 2 Integration with 3 Enhanced
Machine Electronic Decision
Learning Health Records Support
AI technology AI tools will
will continue to The integration provide
evolve, of AI-assisted enhanced
leveraging pathology decision
advanced coding systems support,
machine with electronic assisting
learning health records medical coders
algorithms to will enable in making
improve seamless data informed and
accuracy and exchange and accurate code
efficiency in enhance coding assignments.
pathology workflows.
AI-assisted Pathology Coding:
Benefits and Challenges
Benefits Challenges
• Increased productivity • Data quality and standardization
• Improved accuracy • Unstructured report interpretation
• Enhanced compliance • Continuous training and updates
Conclusion: AI in Pathology Coding
AI-assisted pathology coding is revolutionizing the healthcare
industry, empowering medical coders with advanced tools to
efficiently analyze pathology reports and assign accurate codes. As
AI technology continues to evolve, we can expect even greater
improvements in efficiency, accuracy, and decision support.
Embracing AI in pathology coding will lead to better patient care and
optimized coding workflows. The future of pathology coding is here.
Embrace the power of AI!
