Pathology/Lab Coding Alert

Solve physician professional pay problem.

As CPT® 2013 jettisons 83912 (Molecular diagnostics; interpretation and report), you’ll need to find a new way to capture your pathologist’s professional interpretation of molecular pathology tests.

You’ll also need to see what can be done -- if anything -- to capture a similar service performed by a laboratory scientist instead of a physician.

That Was Then

"When labs used the stacking codes to describe molecular tests, they had the option of reporting 83912-26 (… Professional component) to capture the pathologist’s interpretation," says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha. Medicare paid for this service on the Physician Fee Schedule (PFS), meaning that only physicians could charge for the interpretation.

CLFS paid, too: But the Clinical Laboratory Fee Schedule also paid a (lesser) fee for 83912, billed without modifier 26. Labs billed that fee when a PhD or other appropriately-trained laboratory scientist evaluated and reported on the molecular test results.

Problem: With CPT® 2013’s deletion of 83912 and the fact that CMS will pay for molecular tests on the CLFS instead of the PFS, how can you capture the professional work if a physician interprets a molecular test?

This is Now

The solution lies in a new HCPCS 2013 Level II code -- G0452 (Molecular pathology procedure; physician interpretation and report).

CMS introduced the code because, "in some cases, a physician interpretation of a molecular pathology test may be medically necessary to provide a clinically meaningful, beneficiary-specific result," states the PFS final rule published in the Nov. 16, 2012 Federal Register.

Restrict use: CMS expects you to use G0452 only when the physician performs a "medically necessary interpretation and written report of a molecular pathology test, above and beyond the report of laboratory results."

G0452 is a professional-only code that CMS considers a "clinical laboratory interpretation service." As such, you’ll need to meet the following three requirements to use the code:

1. Request for interpretation by the patient’s attending physician

2. Exercise of medical judgment by consulting physician

3. Results written in a narrative report included in the patient’s medical record.

Effective Jan. 1, 2013, CMS deletes 83912-26 from the list of acceptable codes for clinical lab interpretation service and adds G0452.

No fee for lab scientists: Unlike the old system that allowed a lab scientist to bill 83912 for evaluating and reporting on a molecular test, CMS and CPT® don’t provide a mechanism for lab-scientist billing under the new system.

According to CMS, "We do not believe it is appropriate to establish a HCPCS G-code on the CLFS for the interpretation and report of a molecular pathology test by a doctoral-level scientist or other appropriately trained nonphysician health care professional. … Payment for the interpretation and report service would be considered part of the overall CLFS payment for the molecular pathology CPT® codes."