Pathology/Lab Coding Alert

Billing a physician service?  That could be fraud

Because a pathologists' assistant routinely performs gross exams, the PA can bill for "gross-only" surgical consultation code CPT 88329 --right? Not so fast.

You have to be a physician to bill for services paid under the Medicare Part B Physician Fee Schedule, and that includes 88329 (Pathology consultation during surgery). Although a growing number of pathologists appear to be billing for intra-operative consultations performed by their PAs, that's a risky practice they shouldn't be doing, says Joe Musselman, PA(ASCP), QIHC, CPC, CCP, pathologists' assistant at North Dallas Pathology.

The only exception allowing a nonphysician practitioner to bill for a physician service is "incident-to" billing, and PAs don't meet Medicare's requirements for that. See "Billing Corner: Don't Ignore Incident-to Rules" at right for a brief explanation of incident-to.

Pathologist Must Attend Surgery

If a PA goes to the operating room to provide an intra-operative gross consultation and the pathologist later reviews it, that's not good enough to bill 88329. An intra-operative consultation must take place during surgery because the results may influence the course of the procedure.

That means 88329 requires the pathologist's presence during surgery to consult with the surgeon. "The code does not describe a service that the pathologist can provide by looking at a specimen after the surgical procedure," Musselman says.

Know the Difference Between Grossing and Diagnosing

Performing the gross exam of surgical pathology specimens is something that PAs do every day as a primary part of their jobs. But you have to know where the PA's responsibility ends and the pathologist's responsibility begins.

"The key is whether the gross exam results in a diagnosis," says Pamela Younes, MHS, HTL (ASCP), CPC, PA (ASCP), assistant professor at Baylor College of Medicine in Houston. Providing a final diagnosis is a professional service that a physician must provide for procedures paid under the Medicare Physician Fee Schedule. 

Result: A PA can perform the gross exam of any surgical pathology specimen listed under 88302-88309 (Level II-VI - Surgical pathology, gross and microscopic examination). "The PA may gross the specimen, but the pathologist performs the microscopic exam," Younes says. "Then the pathologist reaches a diagnosis based on observations from the gross and microscopic exams."  
  
Caution: Even though the PA might perform a gross-only exam (88300, Level I - Surgical pathology, gross examination only) and dictate the diagnosis, the pathologist is responsible for verifying the diagnosis with a review of the specimen.

PAs Don't Perform Physician Service

Because a PA is not a physician, he cannot render a final diagnosis from a gross specimen exam for either 88329 or 88300. "To bill for these codes, the pathologist should review the gross specimen even if the PA has already done so," Younes says. And remember that to bill for 88329, the pathologist must review the specimen during surgery.

Red flag: Medicare does not recognize the PA(ASCP) certification as a nonphysician practitioner. That means a PA cannot get a Medicare provider number and does not qualify for incident-to billing. The PA should not bill under a supervising pathologist's provider number. The pathologist must file an 88300 or 88329 claim under his provider number--which indicates that he provided the service.