Pathology/Lab Coding Alert

Question: I have been told that a bone marrow smear interpretation includes a technical and professional component, but the code is not listed that way in the Physician Fee Schedule. Our independent pathologist often interprets bone marrow aspiration slides prepared by the hospital lab. How should we bill that service?

Missouri Subscriber

Answer: Although the AMA states that 85097 (Bone marrow, smear interpretation) includes a technical and professional component, you are correct that Medicare's National Physician Fee Schedule does not indicate using the code with modifier -TC (Technical component) or -26 (Professional component). Because of this discrepancy, you must bill 85097 according to the different guidelines established by individual payers.

According to CPT Assistant July 1998, "If only physician services are performed, then 85097 [is] reported with modifier -26. If technical services (such as staining) are also performed by a physician or the laboratory, then the codes should be used without a CPT modifier."

For your scenario an independent pathologist interpreting bone marrow aspiration slides prepared by the hospital lab report 85097-26 if the payer follows AMA reporting guidelines. According to AMA guidelines, report 85097 without the modifier only if the independent lab prepares and interprets the slides.

But for Medicare coverage, report 85097 without modifiers. The Physician Fee Schedule accommodates the additional technical expense when the pathologist/lab prepares and interprets bone marrow smears by providing greater reimbursement in the nonfacility than facility setting. Relative value units (RVUs) for 85097 are 2.72 for nonfacility, and 1.4 for facility. Multiplied by the 2002 conversion factor, Medicare pays $98.46 for nonfacility bone marrow smear interpretation, and $50.68 for the facility (not adjusted for region).

Don't confuse the routine preparation and staining of bone marrow smears with special stains that the pathologist may use. Report special stains separately using the appropriate code, such as +88313 (Special stains [list separately in addition to code for surgical pathology examination]; group II, all other [e.g., iron, trichrome], except immunocytochemistry and immunoperoxidase stains, each) for iron stains used to evaluate iron-deficiency anemia.