Pathology/Lab Coding Alert

Question: When two of my group physicians perform different services for the same case, should I indicate which physician did what procedure on the CMS-1500? We've always reported the pathologist who signs out the case as the performing physician for all services, but I recently heard that this is wrong. What kind of trouble am I in if we've been doing this wrong?

Montana Subscriber

Answer: Sections 2010.2 and 4020.2 of the Medicare Carriers Manual instruct that, when medical services of different physicians in a group are to be reported on a single claim, the physician identification number shown in item 24K of Form CMS-1500 must correlate line-by-line with the physician who actually performed each service. Alternatively, if the group uses item 31 to identify the performing physician, use separate claim records to segregate the medical services according to those personally performed by each physician.

Dennis Padget, CPA, FHFMA, president of Padget & Associates, a pathology compliance-consulting firm in Simpsonville, Ky., recently asked CMS whether pathology group practices might be exempt from this instruction. One of the arguments for exemption is that few anatomic pathology medical reporting software systems support the required charge abstracting.

All physicians, without exception, are subject to the claim reporting provisions of sections 2010.2 and 4020.2, according to CMS. Software deficiencies are not a mitigating circumstance because "the vendors are not complying with the 1500 requirements." When, for example, Dr. A examines and reports the frozen section diagnosis, but Dr. B examines and reports the permanent sections (and signs out the case), Form CMS-1500 must attribute the 88331 code to Dr. A and all other codes to Dr. B. Segregated reporting is not required, however, when Dr. A performs the gross exam portion of a gross and microscopic procedure (e.g., 88305) signed out by Dr. B because the former element is not separately billable in this situation.

Assuming all group physicians are eligible to bill Medicare for their personal professional services, not fulfilling the requirements of sections 2010.2 and 4020.2 does not cause monetary harm. However, Medicare does not have to show damages to challenge a group's compliance. From a practical standpoint, regulators likely would not pursue action against a pathology group whose only violation was periodic failure to accurately correlate medical services with the actual performing physician. Padget says that the best advice is to attain and maintain compliance with all Medicare requirements, whether technical or substantive.

Reader Questions and You Be the Coder were answered and/or reviewed by R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.; and Dennis Padget, CPA, FHFMA, president of Padget & Associates, in Simpsonville, Ky.