Pathology/Lab Coding Alert

Question: When our lab performs a serum protein electhrophoresis and quantifies the fractions, can we bill 84165 with modifier 26 for the pathologist’s interpretation?

Texas Subscriber

Answer: You can’t bill a pathologist’s interpretation for every 84165 (Protein; electrophoretic fractionation and quantitation, serum) test your lab performs, so the answer depends on the details. 

You can bill for a pathologist’s interpretation only if you meet the following “3-Rs” criteria:

• Request: the patient’s attending physician requests the interpretation
• Report: the pathologist documents the interpretation by a written narrative report included in the patient’s medical record
• Render opinion: the interpretation requires the exercise of medical judgment by the pathologist.

Here’s why: Code 81465 is a clinical lab test that Medicare pays for on the Clinical Laboratory Fee Schedule (CLFS). Reporting 81465 without a modifier captures the technical lab test and garners Medicare pay at the CLFS rate. 

But Medicare also pays for 81465-26 (Professional component) and a specific limited number of other clinical lab tests on the Physician Fee Schedule. Billing 81465-26 means that you’re billing for the physician interpretation of the 81465 lab test results.

If your lab performs 81465 and your pathologist fulfills the criteria for performing the interpretation, you should bill 81465 and 81465-26.