Pathology/Lab Coding Alert

Question: We've recently started billing molecular pathology cases for pathologists. There's a debate in our office about whether to add modifier 26 to the charge. Is this modifier necessary for any of the molecular pathology codes?

Virginia Subscriber

Answer: No, you should not report modifier 26 (Professional Component) with any molecular pathology codes in the range 81105-81479.

The codes themselves describe all analytical services for the test, from cell lysis to quantitation and detection of nucleic acids for all variants tested. These are clinical lab tests, not physician services. The codes do not include "interpretation," so you may bill for your pathologist's interpretation of the test under certain circumstances.

Confusion: Because the CPT^® introduction to the molecular pathology section states that you may report modifier 26 with these codes, coders and billers may understandably be perplexed.

But the molecular pathology codes are essentially technical lab tests paid by Medicare on the Clinical Laboratory Fee Schedule (CLFS), not the Physician Fee Schedule (PFS).

Why not 26: You would use modifier 26 only for tests on the PFS in two circumstances, neither of which apply to molecular pathology:

• When the PFS indicates that an unmodified code represents a "global service" and lists the code with modifiers TC (Technical component) and 26, or
• When the PFS indicates that the test is one of a few select lab tests that may require an interpretation, which you should report with modifier 26 if you meet certain criteria.

Alternative: If your pathologist interprets a molecular pathology test, CMS provides a distinct code to describe the service, instead of reporting the lab code with modifier 26. The code is G0452 (Molecular pathology procedure; physician interpretation and report).

Caution: You can use G0452 only "to report medically reasonable and necessary interpretations of molecular pathology procedures by physicians (M.D. or D.O.)," not by a laboratory scientist according to CMS. You can report only one unit of G0452 per molecular pathology test per specimen. Also, you must meet the same"3 R's" required for a pathology consultation, which are:

• Request for interpretation by the treating physician
• Render medical opinion (requires exercise of medical judgment)
• Report findings in a written narrative.