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US · guidance

CMS SOM App. C, Tag D5607

§493.1273 Standard: Histopathology

activein force · 2026-07-22 – presentas-observed

(d) Tissue pathology reports must be signed by an individual qualified as specified

in paragraph (b) or, as appropriate, paragraph (c) of this section. If a computer

report is generated with an electronic signature, it must be authorized by the

individual who performed the examination and made the diagnosis.

Interpretive Guidelines §493.1273(d)

The laboratory must ensure that only those individuals qualified to evaluate

histopathology specimens can release his or her electronic signature for reporting

purposes.

The tests in histopathology include both gross examination (macroscopic) and

microscopic examination of the slide(s) with evaluation and diagnostic interpretation, and

diagnostic findings reported.

In the event of a computer-generated signature, the laboratory must ensure that the

system is protected from use by unauthorized individuals.

If the technical supervisor who performed the examination and diagnosis is not available

to sign the report, an individual, also qualified as a technical supervisor in

Histopathology, must reexamine and diagnose in order to sign out the report.

History

Rev. 233; Issued: 09-12-25; Effective: 09-12-25; Implementation: 09-12-25

Provenance

Source
cms.gov
Retrieved
2026-07-22
Edition
som-2026-07-22
Content hash
b87c9d1b61b76e3749e4453f3bc22b901a49c32571da0f2ea6c40da41901d7f2
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