Pathology/Lab Coding Alert

Question: We are an anatomic pathology lab and our pathologists will send cases to an outside reference lab for testing, such as T-cell receptor gene rearrangement. We’ve been told that Medicare won’t cover these tests (81340/81342), and that we’re responsible, as the ordering provider.

We don’t have contact with the patient, but is there a way for us to get an ABN, either proactively or retroactively, so we can bill the patient?

Answer: You are correct that if you have a signed Advanced Beneficiary Notice of Non-coverage (ABN) notifying the patient that you don’t expect Medicare to cover the test, you can bill the patient. But the patient must sign the ABN in advance of the specific service, so a retroactive solution is out of the question. Although it’s true that you don’t have patient contact, it’s equally true that the reference lab does not.

Who orders: In this case, your pathologist is the “ordering physician” for the additional tests on the pathology specimen. CMS has clarified that pathologists can order additional tests if they fulfill these conditions:

• The pathologist documents that the service is medically necessary to reach a diagnosis
• The pathologist communicates the results to the treating physician, who uses the results in treating the beneficiary

Because your pathologist is the ordering physician, it is your responsibility to get the signed ABN. You’ll need to establish a protocol in your practice for doing so. Consult your compliance officer to ensure that you’re doing this in an appropriate manner.