Pathology/Lab Coding Alert

Question: I performed a fine needle aspiration biopsy on a breast mass (88170). Medicare denied payment, saying, Our records indicate that you billed diagnostic test(s) subject to price limitations; however, you did not indicate whether the tests were performed by an outside entity or if no purchased tests are included on the claim. How should I code this?

Connecticut Subscriber

Answer: Sometimes, a provider will purchase part of a diagnostic test (the technical or professional component) from an independent entity, and pass these charges on when billing Medicare. Medicare limits the amount that can be charged, however, and will not allow a purchasing provider to charge any markup. Box 20 of the HCFA 1500 form is reserved to identify those diagnostic services purchased from an independent laboratory or diagnostic facility, as well as the amount paid for them, to indicate compliance with these guidelines.

The fine needle aspiration codes have a technical and professional component in the Medicare fee schedule database, evidently to indicate that the physician doesnt always provide the technical component (e.g., the cost of the needle and supplies for smear preparation). If you performed the entire procedure and provided the supplies, bill the global procedure. If performing it in a hospital or facility where you are not responsible for the technical component, bill with modifier -26 (professional component). In either case, check No in box 20 and you should receive payment.