Pathology/Lab Coding Alert

Apply these tactics for reporting 80500-80502 and interpretations

When your pathologist provides a professional opinion on a clinical lab test result, don't miss out on proper pay. Here's how to distinguish -interpretation- from -consultation- and how to accurately report the physician service. Capture Professional Pay for Clinical Lab Test Interpretation By regulation, Medicare provides a class of covered pathologist professional services known as -clinical laboratory interpretation services.- These are specific lab tests that frequently require interpretation by a pathologist. Table 1 on page 84 shows the 20 tests that comprise the class.

Most private insurers and managed-care companies have adopted Medicare's classification and list of clinical laboratory interpretation services. -Because many other payers follow Medicare's lead on clinical test interpretation by pathologists, you should be familiar with Medicare coverage rules,- says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc., a pathology business practices company in Simpsonville, Ky., publisher of Pathology Service Coding Handbook.

To claim the pathologist's professional interpretation of a lab test listed in Table 1, you must first meet the following criteria outlined in the Medicare Claims Processing Manual section 60 E:

- Request: The attending physician must request an interpretation. Standing orders by a hospital's medical staff executive committee or other authorized body can satisfy the request requirement for hospital patients, as long as the ordering physician has the opportunity to refuse the interpretation.

- Render medical opinion: The pathologist must give an interpretation that requires exercising medical judgment. Merely restating the numerical test results in narrative form is not an interpretation.

- Report: The pathologist must file a written report of the interpretation, which could be a brief statement and signature on the lab test report. Do this: To report the pathologist's interpretation of results for one of the 20 approved lab tests, list the code with modifier 26 (Professional component). For Medicare, report the charge on a CMS-1500 form filed with the Part B carrier.

Avoid this: Unlike the surgical pathology codes, you won't need modifier TC (Technical component) to report the lab-test technical service. Modifier TC does not apply to the codes on Medicare's clinical lab-test interpretation list because the unmodified code represents the technical service, says Kenneth Wolfgang, MT (ASCP), CPC, CPC-H, CEO of Chargemaster Maintenance Services, a laboratory consultation company in Portland, Ore.

For instance: If an independent lab performs a serum protein electrophoresis test, report the technical service as 84165 (Protein; electrophoretic fractionation and quantitation, serum). If the pathologist interprets the test result under circumstances that meet the -three R-s,- you should also report 84165-26 to claim payment for the interpretation separate from the test performance itself. Other Tests Take Consult Codes 80500-80502 What if an attending physician requests a pathologist's interpretation of a clinical [...]