Pathology/Lab Coding Alert

Question: When we have a request for interpretation on a molecular pathology test in our lab, the lab director evaluates and writes the report on the test results in question. He is not a physician, but holds a PhD. Can we bill G0452 for the interpretation? If not, can we bill 88291?

Ohio Subscriber

Answer: No, you should not bill G0452 (Molecular pathology procedure; physician interpretation and report) for a service provided by a person who is not a physician or other qualified healthcare provider. Nor should you bill 88291 (Cytogenetics and molecular cytogenetics, interpretation and report) for interpretation of a molecular pathology test. Reserve 88291 for interpretation of cytogenetic studies, which involve chromosome analysis such as codes 88245-88289.

Medicare pays for G0452 on the Physician Fee Schedule, and pays for the molecular pathology tests on the Clinical Laboratory Fee Schedule (CLFS). CMS has stated that G0452 is not appropriate for use by a doctoral-level scientist, and that “payment for the interpretation and report service would be considered part of the overall CLFS payment for the molecular pathology codes.”

That’s not all: To bill G0452 when a pathologist performs the interpretation, certain criteria must be met. The attending physician must request the interpretation, the work must be medically reasonable and necessary and require the exercise of medical judgement, and the pathologist must provide a written report. The National Correct Coding Initiative (NCCI) Policy Manual goes on to state that, “If the information could ordinarily be furnished by a non-physician laboratory specialist, the service does not require the exercise of medical judgement.”