|
Term
|
Meaning
|
Examples
|
Laboratory Charges
|
|
not submitted
|
The specimen is not submitted to pathology at all.
|
placenta from normal delivery
|
none
|
|
receipt only
|
The specimen is documented as received but not examined.
|
orthopedic hardware
|
minimal handling
|
|
gross only
|
The specimen examination is limited to a gross description.
|
bone from an uncomplicated arthroplasty
|
minimal handling, minimal pathologist
|
The receipt only submission provides independent evidence that the specimen was removed as well as the time.
General rules:
(1) The specimen is presumed to be normal or unlikely to have significant disease.
(2) The exemption must not compromise the patient’s level of care.
(3) The surgeon assumes responsibility for documenting, describing and disposing of the material removed.
(4) The pathologist can over-ride the exemption and perform a more complete pathologic examination if there are indications to do so.
(5) The list of specimens for which there are exemptions is approved by the Medical Staff and reviewed periodically.
Special situations include::
(1) forensic specimens with chain of custody (bullets, etc)
(2) therapeutic radioactive material
