Pathology/Lab Coding Alert

Thread the PC/TC needle for different services.

If you’ve ever had problems billing your pathologists’ services to Medicare, you might be surprised to learn that you have all the coding and payment information you need right at your fingertips in the Medicare Physician Fee Schedule (MPFS) searchable database.

Look at the following tips for exploiting this resource based on a recent webinar from Part B MAC NGS Medicare.

Tip 1: Anticipate Payment

The MPFS “determines how and what to pay for services provided to Medicare patients,” explained NGS’ Christine Obergfell in the webinar. You’ll find payment amounts in the database that will help you calculate the beneficiary’s coinsurance amount (when applicable) as well, she said. In most cases, the patient’s responsibility will be 20 percent of the fee. You can also find payment amounts for situations such as when you use certain modifiers or if a provider other than a physician is providing the service, she said.

The database will also elucidate any specific payment policies that might impact the reimbursement for a particular code, such as whether multiple procedures performed at one session would prompt a payment reduction in the subsequent services.

Tip 2: Geography Changes Payment Amounts

To pinpoint the amount you’ll receive from your MAC, you’ll have to input your region into the database, since the geographic practice expense is based on your location, said NGS’ Carleen Parker in the webinar. Select your locality and area in your MAC’s database to get a handle on your specific payment amounts.

Tip 3: Differentiate Facility from Non-Facility Amounts

Once you look up a code or code range in the database and you choose either your specific MAC or national payment amount, those codes will come up along with such information as the descriptor, the facility and non-facility payment amounts, and the pay adjustments for any modifiers that might apply.

Higher payments make sense for non-facility payments because, in facilities, the hospital pays for much of the overhead costs, Obergfell said. In the non-hospital setting, the practice owners incur those costs, which results in higher Medicare payments to them.

Tip 4: Master Technical, Professional, or Global Billing for Pathology

If you bill both the technical and professional components of a particular code, you’ll see the global fee in the database. The MPFS also shows what you’d collect if you reported the code with modifier 26 (Professional component) or modifier TC (Technical component), Obergfell said.

Laboratory and pathology codes may represent a technical-only service, a professional-only service, or a global service (both technical and professional) service. The MPFS lists applicable modifiers for each code, helping you decide how and when to append modifier TC or 26 to a code to explain which portion of a service you’re billing.

Pathology: Many pathology procedures represent both a technical and professional service that one or two separate billing entities perform. The technical component includes the equipment, supplies, and technician labor involved in doing the procedure, such as preparing slides, while the professional component generally represents the physician’s evaluation and interpretation. For instance, anatomic pathology codes 88302-88309 (Level …, Surgical pathology, gross and microscopic examination …) include both the technical and professional components.

“If you report one of these codes without a modifier, you’re billing for the global service, which includes both the technical and professional components,” explains R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Ark. But if you’re billing for an entity that performs only the technical or only the professional component, you need to append the appropriate modifier TC or 26 to get paid the appropriate amount. The MPFS lists the payment amount for the codes that take either the TC or 26 modifier.

Lab test interpretation: Although most lab tests are technical services paid on the Clinical Laboratory Fee Schedule (CLFS), Medicare lists certain lab tests, such as 84165 (Protein; electrophoretic fractionation and quantitation, serum) with a 26 modifier on the MPFS. For these tests, if a physician requests a professional interpretation of the test results and the pathologist interprets and reports on the results, you can bill the lab code with modifier 26.

Separate professional/technical codes: Some pathology/ laboratory services have distinct codes for the technical lab test and the professional interpretation, such as 88148 (Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision) for the technical Pap test, and 88141 (Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician) for the physician interpretation of an abnormal Pap test. Never use modifiers 26 or TC with these codes, which the MPFS modifier listing affirms. Similarly, for codes that involve only a pathologist’s professional service, such as “interpretation” codes like 88291 (Cytogenetics and molecular cytogenetics, interpretation and report), the MPFS does not indicate modifiers 26 or TC.

Tip 5: Non-Participating Providers Can Benefit from the Database

You’ll find information on limiting charges in the database, which apply to healthcare professionals not participating in the Medicare program, Obergfell said. “A nonpar provider usually does not accept assignment on claims and their payment amounts are subject to a limiting charge, which equals 115 percent of the nonpar fee schedule amount, which is the maximum amount a nonpar provider can charge a beneficiary on a nonassigned claim.”

Resource: Review coding information in the fee schedule database on your individual MAC’s website or check the national database at www.cms.gov/apps/physician-fee-schedule/overview.aspx.