L864 – Surgical Pathology, Level 4
OHIP Dermatology Code — DIAGNOSTIC AND THERAPEUTIC PROCEDURES · Schedule of Benefits
Surgical Pathology, Level 4 involves the gross and microscopic examination of a surgical specimen. This level typically corresponds to specimens like a large, complex, non-malignant tumor, a malignant tumor with minimal resection margins, or specimens requiring extensive dissection. This service includes all common and specific elements as defined in the Schedule of Benefits, such as obtaining and reviewing information, record keeping, and reporting.
When to Use
- Use L864 for the examination of complex non-malignant tumors or malignant tumors with minimal resection margins that exceed the complexity of L863 but do not meet the criteria for L865.
- Select L864 when the specimen requires extensive dissection and microscopic evaluation that is more labor-intensive than standard biopsies or minor excisions covered under L862 or L863.
Common Pitfalls
- Billing L864 for routine biopsies that should be coded under L862 or L863 will trigger automated rejections or audit flags for upcoding.
- Submitting L864 without a formal pathology report that justifies the level of complexity required for a Level 4 examination is a frequent cause of claim reversal during post-payment audits.
Billing Tips
- Ensure the pathology report explicitly details the dissection process and microscopic findings to support the Level 4 classification if compared against the lower complexity requirements of L863.
Effective: April 1, 2026
J. Diagnostic and Therapeutic Procedures
DIAGNOSTIC AND THERAPEUTIC PROCEDURES
Laboratory
Diagnostic and Therapeutic Procedures
In accordance with the Health Insurance Act, the medical record must establish that: an insured service was provided; the service for which the account is submitted is the service that was rendered; and the service was medically necessary.
If supervised by a Supervising Physician, the service rendered by a Medical Trainee is only eligible for payment when the medical record of the patient identifies the Supervising Physician, the Medical Trainee and level of training, the description of the insured service performed by the Medical Trainee, and patient consent to the Supervision. The Supervising Physician must have reviewed the nature and outcome of the service and the patient record(s) with the Medical Trainee and signed off on the service.
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