Pathology/Lab Coding Alert

Question: If our pathologist is non-participating with Medicare, I thought that meant he cannot provide and bill for a service to a Medicare patient. But someone told me that non-participating physicians with Medicare can still provide services to Medicare patients and collect 95 percent of the fee schedule (with a limiting charge). Is that correct?

Codify Subscriber

Answer: Yes, it is true that a non-participating (non-par) pathologist can still provide and bill for services for Medicare patients. But the payment will be different than what you can expect if the pathologist is a participating provider.

Here are the levels of physician involvement with Medicare:

• Participating (par) physician: This means that you agree to accept assignment for all services provided to Medicare patients. As a par provider, you will be paid the amount approved by Medicare for covered services, which is the Medicare Physician Fee Schedule (MPFS) amount for pathologist professional services.
• Non-par physician: A non-par physician may accept Medicare assignment on a claim-by-claim basis. As a non-par provider, the Medicare-allowed amount is 95 percent of the amount for participating physicians. Depending on whether you take assignment for a specific claim, you face two different payment scenarios:​

           o If you do not accept assignment for a claim: You still must submit a claim to Medicare, but you do not collect anything from Medicare. Instead, Medicare reimburses the patient, and the patient should pay you. You may charge up to 115 percent of the non-par-Medicare-allowed payment amount.
           o If you do accept assignment for a claim: In this case, Medicare will pay you 80 percent of the non-par Medicare-allowed amount (which is 95 percent of what a participating provider gets), and you must bill the beneficiary for the remaining 20 percent.

Laboratory exception: You are required take assignment for laboratory services you perform and bill for. As such, you must accept as payment-in-full the Medicare payment amount, which is fixed on the Clinical Laboratory Fee Schedule instead of the MPFS.