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Medicare Compliance & Reimbursement

LABS:

Let MPFS Status Indicators Show You How To Get Paid

Published on Mon Oct 15, 2007

Harness fee schedule policy rules for the PC/TC modifiers

The Medicare Physician Fee Schedule just shows reimbursement levels for pathologist procedures, right? Wrong. We'll show you how to decipher the MPFS for technical/professional component billing conventions to make sure you get the correct pay--every time.

The MPFS holds the key to payment when you bill for the professional and/or technical components of certain pathology procedures. Two fee-schedule columns provide "payment policy" indicators regarding which services involve professional and/or technical components and how to use modifiers to report the work:

1. PC/TC: The PC/TC (professional component/technical component) indicator column has 10 possible numerals representing the professional or technical service status of each code.

2. Modifier: The modifier column indicates the appropriate modifier to use if the code involves a technical and/or professional component, as indicated in the PC/TC column.

Watch for: The modifier column might be blank, meaning that you should not use a professional or technical modifier with the code. Or the column might list a modifier, indicating that you should report the code with 26 (Professional component) or TC (Technical component), depending on the code and the PC/TC status.

"Because many other payers follow Medicare's lead on clinical test interpretation by pathologists, you should be familiar with Medicare coverage rules," says Dennis Padget, president of DLPadget Enterprises Inc., a pathology business practices company in Simpsonville, KY, publisher of the Pathology Service Coding Handbook.

You should be familiar with the following PC/TC indicators and modifier column entries to obtain proper pay for your pathologist's work, whether for surgical pathology or for a professional opinion regarding clinical lab tests.

PC/TC "0": To specify codes that represent only a physician service, such as clinical laboratory consultation 80500 or 80502, the fee schedule lists a "0" in the PC/TC column.

This corresponds to a blank in the modifier column, meaning you shouldn't append 26 or TC to these codes.

Other codes in this "0" category that pathologists frequently report include physician blood bank codes (86077-86079, Blood bank physician services ...), certain outside slide consults such as 88321 (Consultation and report on referred slides prepared elsewhere) and 88325 (Consultation, comprehensive, with review of records and specimens, with report on referred material), surgical consult 88329 (Pathology consultation during surgery), and bone marrow aspiration and biopsy codes 38220 and 38221 (Bone marrow ...).

PC/TC "1": You'll find a "1" in the PC/TC column for certain diagnostic pathology procedures that have both a professional and technical component paid on the MPFS. Correspondingly, the modifier column indicates you can report the global service (PC and TC) or report each component separately.

For the technical service, the modifier column shows TC. For the professional service, the modifier column lists 26.

Don't miss: For the global service, the modifier column lists no modifier. Billing the code without a modifier when you've provided only one component of the service is fraudulent--the un-modified code represents both the technical and professional services.

For example: Surgical pathology services such as 88305 (Level IV--Surgical pathology, gross and microscopic examination) have a technical component--including materials and technologist slide preparation--and a professional component--involving the pathologist's specimen examination and interpretation.

Reporting 88305 without a modifier represents the global service, which includes the technical and professional components, says Kenneth Wolfgang, CEO of Chargemaster Maintenance Services, a hospital and laboratory consultation company in Portland, OR.

To report the technical service only, you should report 88305-TC. For the professional service, report 88305-26.

PC/TC "2": When codes represent only a physician service but correspond to an associated technical code, the fee schedule lists "2" in the PC/TC column and shows no modifier in the modifier column. Remember: You should not append 26 or TC to these codes.

PC/TC "3": Codes listed on the MPFS that represent only a technical service have a "3" in the PC/TC indicator column.

For instance, Medicare considers 86580 (Skin test; tuberculosis, intradermal) a technical-only code, so the "3" in the PC/TC column corresponds to no modifier in the modifier column. When you bill 86580, you're only billing a technical fee, so you don't need to append TC.

PC/TC "6": Medicare covers a pathologist's professional service (PC) for "clinical laboratory interpretation" for 20 lab tests. These are specific tests that frequently require interpretation by a pathologist.

Bottom line: If you see a "6" in the PC/TC column, you're looking at one of the 20 lab codes, and you can bill for your pathologist's test result interpretation if you meet the criteria discussed in last month's article. You'll also see "26" in the modifier column for these codes. Translation: You should report the clinical lab test professional interpretation by appending 26 to the lab code.

Key: For these 20 tests, Medicare pays for the pathologist's interpretation via the Physician Fee Schedule when you list the code with modifier 26, regardless of site of service, Padget says.

On the other hand, Medicare pays the facility technical charge from the Clinical Laboratory Fee Schedule for hospital outpatients and non-hospital patients when you list the code without a modifier.

PC/TC "8": The Physician Fee Schedule lists one lab code with numeral "8" in the PC/TC column--85060 (Blood smear, peripheral, interpretation by physician with written report). Medicare defines "8" as a physician interpretation service for an abnormal smear from a hospital inpatient.

"According to Medicare, any blood smear for a non-inpatient includes the smear interpretation, regardless of whether the smear is from an atypical CBC or is part of a bone marrow case," Padget says. "Furthermore, you can't substitute another code--such as 80500--for 85060 to get paid on a smear interpretation for a non-inpatient: that would constitute a false claim."

PC/TC "9": If you see a "9" in the PC/TC column, it means that the concept of professional and technical components is not applicable. Medicare used to list all lab codes on the MPFS and would identify those paid on the CLFS with a "9" in the PC/TC column.

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