Pathology/Lab Coding Alert

Despite the common perception that a clinical pathology consultation and the interpretation of a clinical laboratory test are one and the same, Medicare defines these as two separate and distinct types of physician services. To facilitate payment, you must know which clinical laboratory tests may involve a professional interpretation and how to report that service in the independent laboratory and hospital setting. Bill for Interpretation of Diagnostic Tests "A pathologist's interpretation of laboratory diagnostic tests is a professional service that is payable under the Physician Fee Schedule," says Kenneth Wolfgang MT (ASCP), CPC, CPC-H, member of the national advisory board of the American Academy of Professional Coders and director of coding and analysis for National Health Systems Inc., a coding consultation company in Camp Hill, Pa. Many CPT Codes for clinical laboratory tests describe the lab work (with pathologist oversight) involved in the test, which is payable under the Clinical Laboratory Fee Schedule (CLFS). "If a pathologist provides an interpretation of the test, the interpretation is separately billable," Wolfgang says.

"However, only 18 specific clinical lab tests are recognized by Medicare as frequently requiring interpretation," says Dennis Padget, CPA, FHFMA, president of Padget & Associates, a Kentucky-based pathology compliance-consulting firm. "Included are hemoglobin electrophoresis (83020), molecular diagnostics (83912), protein electrophoresis and Western blot (84165, 84181, 84182), immunoelec-trophoresis (86320-86327) and fluorescent noninfectious agent antibody tests (86255, 86256)." Section 15020-E of the Medicare Carriers Manual (MCM) contains the complete list.

Even for these 18 diagnostic lab tests, Medicare covers the pathologist's interpretation only if it meets three criteria:

1. The patient's attending physician requests the interpretation. 2. The interpretation is documented by a written narrative report included in the patient's medical record.

3. The interpretation requires the exercise of medical judgment by the pathologist. "CMS states that for this category of pathologist professional service, the standing order of a hospital's medical staff may be used as a substitute for the individual request by the attending physician," Padget says. Coders must append modifier -26 (Professional component) to the appropriate lab code (e.g., 83020, 84165, 86320, 86334) to report the pathologist's interpretation of a clinical diagnostic test included in this list of 18 tests. The test is reported with the appropriate CPT code, such as 86334 (Immunofixation electrophoresis), and is payable under the CLFS; the pathologist's interpretation is reported as 86334-26 and is payable under the Physician Fee Schedule (PFS).

The National PFS Relative Value File (RVU02, available at www.hcfa.gov/stats/pufiles.htm) describes coding and reimbursement for pathologist interpretation of diagnostic tests. Column M is labeled "PC/TC indicator," and the code in that column gives information [...]