Pathology/Lab Coding Alert

Question: We have a PhD performing molecular diagnostics and molecular array testing in our lab. How can we bill the interpretation -- the professional component of his work?

Indiana Subscriber

Medicare prohibits Part B professional fee payment to PhDs, instead limiting reimbursement to physicians (and certain other practitioners in some cases). Most states have laws restricting medical practice to physicians (such as M.D.s). That means a PhD can't legally render -- or bill for -- an interpretation service that involves "the practice of medicine."

Medicare has given some direction for billing when PhDs perform molecular diagnostics and array testing, however.

List arrays with TC: Codes 88384-88386 (Array-based evaluation of multiple molecular probes ...) include both a technical and professional component. You can only bill the professional work using a global charge or with modifier 26 (Professional component) when a physician (such as a pathologist) performs the work. According to the Correct Coding Initiative policy manual version 15.3, if a "laboratory scientist or technician rather than a physician," such as a PhD, performs the work, you can't bill the global codes. Instead, you should report the appropriate code (such as 88385) with modifier TC (Technical component) "which includes the non-physician work including interpretation," according to the policy manual.

Get clinical lab pay for 83912: Unlike array codes 88384-88386 that include the professional interpretation in the global service, molecular diagnostics billing involves a separate code for the professional interpretation: 83912 (Molecular diagnostics; interpretation and report). Physician payment for this code on the Medicare physician fee schedule is $18.40 (national amount for 83912-26 using conversion factor 36.0846). You can't bill 83912-26 if a PhD performs the service. Instead, you should bill 83912 with no modifier, which Medicare pays on the Clinical Laboratory Fee Schedule at $5.74 (2010 National Limit Amount).