Pathology/Lab Coding Alert

Question: You stated in an earlier Q/A [-Scrutinize Technical Component for 85097,- Pathology/Lab Coding Alert September 2006] that a hospital cannot bill 85097-TC to Medicare for preparing bone marrow aspiration slides that an independent pathologist interprets. Is this true for all cases, whether an inpatient, outpatient or non-hospital patient?


Kentucky Subscriber


Answer: No, the answer applies only to billing Medicare Part B for a non-hospital patient using Form CMS-1500. Although a hospital can't bill 85097-TC using the Physician Fee Schedule for a non-hospital patient, let's look at other billing scenarios.

If you assume the bone marrow aspirate is from a hospital outpatient, the hospital can bill for the technical component of 85097 (Bone marrow, smear interpretation). The hospital would bill the Medicare Part A fiscal intermediary on Form CMS-1450 (UB-92) for routine technical services associated with a bone marrow aspirate smear (85097) for a hospital outpatient (type of bill 13x). Medicare would pay for 85097 under the Outpatient Prospective Payment System APC fee schedule.

Similarly, the hospital can bill for the technical component of bone marrow aspirate smear for a hospital inpatient, and Medicare will pay for the service as part of the diagnosis-related group (DRG) that captures all services performed during the inpatient stay.

Tip: Medicare payment rules differ depending on the fee schedule that applies to the specific situation: (1) what lab service you-re billing; (2) who rendered the service; (3) who's billing the service; and (4) where the patient was at the time the sample was taken.

For example: A physician can only bill under the Medicare Physician Fee Schedule, but an independent lab can bill under both that schedule and the Clinical Lab Fee Schedule. Neither a physician nor an independent lab can bill under the hospital Inpatient Prospective Payment System (DRG) or Outpatient Prospective Payment System (APC) fee schedules.

Don't miss: A hospital has the capacity to bill under all four fee schedules depending on the particular lab service (whether anatomic or clinical lab) and patient place of service (whether hospital inpatient, outpatient or non-hospital patient).

Note: Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., a pathology business practices publishing company in Simpsonville, Ky., assisted with this answer.