Pathology/Lab Coding Alert

Apply these tactics for reporting 80500-80502 and interpretations

When your pathologist provides a professional opinion on a clinical lab test result, don't miss out on proper pay. Here's how to distinguish -interpretation- from -consultation- and how to accurately report the physician service.

Capture Professional Pay for Clinical Lab Test Interpretation

By regulation, Medicare provides a class of covered pathologist professional services known as -clinical laboratory interpretation services.- These are specific lab tests that frequently require interpretation by a pathologist. Table 1 on page 84 shows the 20 tests that comprise the class.

Most private insurers and managed-care companies have adopted Medicare's classification and list of clinical laboratory interpretation services. -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, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., a pathology business practices company in Simpsonville, Ky., publisher of Pathology Service Coding Handbook.

To claim the pathologist's professional interpretation of a lab test listed in Table 1, you must first meet the following criteria outlined in the Medicare Claims Processing Manual section 60 E:

- Request: The attending physician must request an interpretation. Standing orders by a hospital's medical staff executive committee or other authorized body can satisfy the request requirement for hospital patients, as long as the ordering physician has the opportunity to refuse the interpretation.

- Render medical opinion: The pathologist must give an interpretation that requires exercising medical judgment. Merely restating the numerical test results in narrative form is not an interpretation.

- Report: The pathologist must file a written report of the interpretation, which could be a brief statement and signature on the lab test report.

Do this: To report the pathologist's interpretation of results for one of the 20 approved lab tests, list the code with modifier 26 (Professional component). For Medicare, report the charge on a CMS-1500 form filed with the Part B carrier.

Avoid this: Unlike the surgical pathology codes, you won't need modifier TC (Technical component) to report the lab-test technical service. Modifier TC does not apply to the codes on Medicare's clinical lab-test interpretation list because the unmodified code represents the technical service, says Kenneth Wolfgang, MT (ASCP), CPC, CPC-H, CEO of Chargemaster Maintenance Services, a laboratory consultation company in Portland, Ore.

For instance: If an independent lab performs a serum protein electrophoresis test, report the technical service as 84165 (Protein; electrophoretic fractionation and quantitation, serum). If the pathologist interprets the test result under circumstances that meet the -three R-s,- you should also report 84165-26 to claim payment for the interpretation separate from the test performance itself.

Other Tests Take Consult Codes 80500-80502

What if an attending physician requests a pathologist's interpretation of a clinical lab test that is not on Medicare's list of 20 approved clinical laboratory interpretation services? You may be able to bill a clinical pathology consultation (80500 or 80502) instead.

To be eligible for Medicare payment, a pathologist's -clinical consultation service- (80500-80502) must meet the same criteria as an interpretation service, plus one more, according to the Medicare Claims Processing Manual section 60 D:

- Request: The patient's attending physician must order the consultation, not just the underlying lab test. -Unlike the lab-test interpretation service, CMS has outlawed standing orders as a way to fulfill the attending-physician request for a clinical pathology consultation,- Padget says.

- Render: The consultation must involve the exercise of medical judgment by the consulting physician. Medicare and most private insurers take the position that a lab test that the ordering physician can readily interpret doesn't warrant consultation by a pathologist under ordinary circumstances, Padget says.

- Report: The pathologist must issue a written consultation report. Beware: You may be denied payment if you mislabel a -consultation- (80500-80502) as an -interpretation,- and vice-versa.

- Relate: The consultation must relate to a lab test result that lies outside the clinically significant normal or expected range in view of the patient's condition. -In general, if the test result is -normal,- you can pretty much forget about billing a pathologist's consultation service, even though you don't know for sure that it's normal until the pathologist says it is,- Padget says.

Don't use modifier 26: Unlike the lab test interpretation service, the consultation does not require modifier 26. Codes 80500 and 80502 are professional-only services, according to the Claims Processing Manual, so the idea of a professional -component- does not apply.

Do use modifier 59: Because an independent lab must bill Medicare Part B for both the underlying lab test and the consultation, you-ll have to use modifier 59 (Distinct procedural service) if the lab test is one of many that the Correct Coding Initiative (CCI) bundles with 80500 and 80502. See -Think CCI Halts Clinical Pathology Consultation? Think Again- on page 83 for more on overriding the CCI consultation edits.

Warning: Medicare, managed-care companies, and private insurers presume that attending physicians are able to interpret most laboratory tests under ordinary circumstances. That's why payers expect clinical consultation service charges (80500-80502) by pathologists to be rare.

Don't be intimidated by this payer mindset, but make certain all of your clinical consult charges fully meet the -four R-s- and that you-re not abusing this category of professional services.

Note: You can access the Medicare Claims Processing Manual (CMS IOM Pub. 100-4) section 60 on the Internet at www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.