Consultation and report on referred slides prepared elsewhere
CPT4 code
Name of the Procedure:
Consultation and Report on Referred Slides Prepared Elsewhere
- Common Name: Second Opinion Slide Review
- Technical Terms: Slide Consultation, Pathology Slide Review
Summary
A consultation and report on referred slides involve a pathologist reviewing pathology slides that were prepared at another medical facility. The goal is to provide a second opinion or a more specialized interpretation of the findings on these slides.
Purpose
This procedure is conducted to ensure an accurate diagnosis by obtaining a second opinion on pathology slides. It can confirm initial findings, offer a different interpretation, or provide additional insights that can impact treatment decisions.
Indications
- Uncertain or ambiguous initial diagnoses.
- Patient's request for a second opinion.
- Complex or rare conditions that require specialized expertise.
- Discrepancies between clinical findings and pathology reports.
Preparation
Generally, no specific preparation is required from the patient as the slides are usually sent directly between medical facilities. However, patients should ensure that their complete medical records and any previous pathology reports are available to the consulting pathologist.
Procedure Description
- Receiving Slides: The pathology slides are sent from the originating medical facility to the consulting pathologist.
- Initial Review: The consulting pathologist examines the slides to understand the initial diagnosis and assess the quality of the slide preparation.
- Detailed Analysis: Through a microscope, the pathologist reviews the slides in detail, looking for cellular structures, abnormalities, or specific markers indicative of certain diseases.
- Comparison and Interpretation: Based on the findings, the pathologist compares the observations with the initial report and any relevant medical standards.
- Report Generation: A detailed report is generated, summarizing the findings and providing the pathologist's expert opinion. This may include confirming, refuting, or providing additional insights beyond the initial diagnosis.
Duration
The procedure typically takes a few days to a week, depending on the complexity of the slides and the pathologist's schedule.
Setting
This procedure is usually performed in a pathology lab at a hospital or a specialized pathology center.
Personnel
- Consulting Pathologist
Risks and Complications
- Common Risks: Miscommunication or errors in transferring slides.
- Rare Risks: Damage to slides during transportation, which may necessitate repeat slide preparation from the original tissue samples.
Benefits
- Accuracy: Increased diagnostic accuracy and confidence in the diagnosis.
- Specialized Insights: Access to specialized knowledge for complex cases.
- Treatment Planning: Better-informed treatment planning based on a thorough review.
Recovery
There are no physical recovery requirements for the patient as the procedure involves only the review of slides without any direct interaction with the patient.
Alternatives
- Repeating the Biopsy: In some cases, a repeat biopsy might be suggested, though this is invasive.
- Molecular/Genetic Testing: Additional testing on the original tissue samples for further insights.
- Clinical Correlation: Relying more on clinical findings and other diagnostic tests.
Patient Experience
- During the Procedure: The patient does not need to be present during the review.
- After the Procedure: The patient will receive the consulting pathologist's report through their primary healthcare provider, with explanations and next steps discussed in a follow-up appointment.
Pain management or comfort measures are not applicable for this procedure as it does not involve any physical examination or intervention on the patient.