Pathology/Lab Coding Alert

Question: Medicare doesn't pay for 85060 for outpatients. Can I submit this code with a modifier to receive payment?

Texas Subscriber

Answer: No, a modifier is not available to achieve payment for 85060 (Blood smear, peripheral, interpretation by physician with written report) for Medicare beneficiaries who are outpatients.

Medicare will only pay for 85060 for hospital inpatients (place of service 21). You're most likely to see 85060 as part of a bone marrow case billed as 85097 (Bone marrow, smear interpretation) and 88305 (Level IV - Surgical pathology, gross and microscopic examination, Bone marrow, biopsy). Those cases are typically inpatient services, and you can get paid for the peripheral smear (85060).

Not for outpatient: If your pathologist performs an 85060 service for an outpatient, such as a reflex from an abnormal complete blood count (such as 85027, Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count]), you can't separately charge for the 85060 for a Medicare patient. Other payers may not have the same restriction.

No work-around: Some billers have tried to get around the Medicare outpatient restriction by billing the peripheral smear with a consultation code such as 80500 (Clinical pathology consultation; limited, without review of patient's history and medical records). Doing so would be fraudulent, and you shouldn't do it.