Pathology/Lab Coding Alert

The global codes include services such as surgical pathology procedures 88302-88309 (Level … - Surgical pathology, gross and microscopic examination …), many ancillary procedures such as 88312-88319 (Special stain including interpretation and report …), and many nongynecological cytopathology procedures such as 88104-88121 (Cytopathology…).

Tip: For Medicare payers, you can pinpoint codes with separate technical and professional components by consulting the Medicare Physician Fee Schedule search tool on the Centers for Medicare and Medicaid Services (CMS) website at www.cms.gov/medicare/physician-fee-schedule/search.

Other codes that labs bill may be technical-only or professional-only codes. You need to know the difference if you want to bill these codes correctly.

Clinical laboratory: Codes paid on the Clinical Laboratory Fee Schedule (CLFS) represent technical-only codes. These include chemistry tests such as glucose, 82947 (Glucose; quantitative, blood (except reagent strip)), and microbiology tests such as strep test 87651 (Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique). Unlike nongynecological cytopathology procedures, Pap test codes for gynecological cytopathology procedures such as 88142-88153 (Cytopathology … cervical or vaginal …) also describe technical-only services.

Professional: Certain codes that pathologists use describe a professional-only service. These are generally codes that describe just “interpretation and report” or “consultation.”

For instance, the following codes describe a pathologist’s professional interpretation of a technical lab test described by a separate code:

• 88141 (Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician)
• 88187-88189 (Flow cytometry, interpretation …)
• 88291 (Cytogenetics and molecular cytogenetics, interpretation and report)
• 85097 (Bone marrow, smear , peripheral, interpretation by physician with written report)
• 85060 (Blood smear interpretation)

If another physician requests a consultation from a pathologist for abnormal clinical lab test results, professional-only codes 80503-+80506 (Pathology clinical consultation …) describe the pathologist’s professional work based on the time spent or the complexity of the medical decision making involved.

3 R’s: For the pathologist to perform a consultation service, they must meet the 3 R’s. “That means the pathologist must receive a request for consultation from a qualified healthcare provider, render a medical opinion, and report the findings in writing,” explains R.M. Stainton Jr., MD, president of Doctors Anatomic Pathology Services in Jonesboro, Arkansas.

Break Out Global Components

The most straight-forward use of modifiers 26 and TC is to help you bill the component of a global code that you performed when a separate entity performed the other component.

TC: TC is a HCPCS Level II modifier, which covers the provision of all equipment, supplies, personnel, and costs related to performing the procedure. For instance, if your lab prepares special stain slides for a pathologist who is not part of your lab, you should bill the code with modifier TC. When you report the technical component, your lab will get paid for the equipment, supplies, and staff involved in preparing the special stain slides.

26: This is a CPT^® modifier that describes a physician’s professional services that aid in determining a medical diagnosis when a separate entity performed the technical service. For instance, in the prior example, the pathologist who interpreted the special stain slides would bill the same code with modifier 26.

Pitfall: People sometimes abbreviate the professional component as PC, but there is a modifier with those exact characters that identifies something completely different. Modifier PC (Wrong surgery or other invasive procedure on patient) is used to identify when a provider performs an incorrect procedure on a patient.

Use 26 for Special Interpretation

Don’t confuse an 80503-+80506 consultation service with the pathologist’s interpretation of a clinical lab test. Medicare has designated 18 lab tests that have a “professional interpretation” component paid under the MPFS.

The list includes hemoglobin electrophoresis (83020), protein electrophoresis and Western Blot (84165, 84181-84182, and 88371-88372), fibrinolysins (85390), platelet aggregation (85576), fluorescent noninfectious agent antibody tests (86255-86256), immunoelectrophoresis (86320-86327), immunofixation electrophoresis (86334), dark field examination (87164), inclusion bodies smear (87207), and light-microscope crystal identification (89060).

3 R’s again: For the pathologist to perform a clinical lab test interpretation service, they must meet the same 3 R’s criteria required for a consultation. One difference is that standing orders will suffice for the interpretation request for these codes.

Use modifier 26: Rather than using a consultation code to report interpretation of these tests, the pathologist should bill the service using the appropriate laboratory code with modifier 26 (Professional component).

Example: The hospital lab examines synovial fluid from a patient’s knee using polarized light microscopy to evaluate for conditions such as gout. The lab has a standing order for this procedure for the pathologist to review the test results, render an opinion, and issue a report.

Solution: The hospital lab should bill 89060 (Crystal identification by light microscopy with or without polarizing lens analysis, tissue or any body fluid [except urine]) for performing the light microscopy. The pathologist should report 89060-26 for the professional interpretation.

Key: You should not use modifier TC in this case. The lab code describes a technical-only lab test that is paid on the CLFS. The MPFS does not list modifier TC for this code (or any of the 18 codes), but does list the codes with modifier 26 for payment of the physician professional service.

Note: For the lowdown on other modifiers you’ll commonly use in your lab, see “Improve Lab Claims’ Success With Proper Modifiers” in Pathology/Lab Coding Alert, Volume 23, Number 5.