Contents of a Pathology Report
The National Cancer Institute defines the contents of a pathology report usually to include:
- Patient information such as Name, birth date, biopsy date.
- Gross description such as Color, weight, and size of tissue as seen by the naked eye.
- Microscopic description such as how the sample looks under the microscope and how it compares with normal cells.
- Diagnosis such as type of tumor/cancer and grade (how abnormal the cells look under the microscope and how quickly the tumor is likely to grow and spread).
- Tumor size: Measured in centimeters.
- Tumor margins: There are three possible findings when the biopsy sample is the entire tumor:
- Positive margins mean that cancer cells are found at the edge of the material removed.
- Negative, not involved, clear, or free margins mean that no cancer cells are found at the outer edge.
- Close margins are neither negative nor positive.
- Other information: Usually notes about samples that have been sent for other tests or a second opinion.
- Pathologist?s signature and name, and address of the laboratory.
?Reports are the work product of the interpretation of test results the introduction of the CPT(R) codebook confirms. Some CPT descriptors specifically require interpretation and reporting to report that code,? neither the American Medical Association nor the Centers for Medicare & Medicaid Services (CMS) state exactly what the ?interpretation and reporting? entails.
Lacking clear guidelines from CPT(R) or payers, providers must rely on recommendations from advocacy and academic groups, or their own best judgment.