modifier 26 is not applicable for this code. Below describes this was created to pay pathologists on the physician fee schedule because it has interpretation and report in the code descriptor.
Molecular Pathology Tests to Be Paid on CLFS New molecular pathology test codes will be placed and priced on the clinical laboratory fee schedule (CLFS) in 2013, the Centers for Medicare and Medicaid Services (CMS) has determined. For tests that require a physician interpretation, CMS is creating a new code for use on the physician fee schedule – G code G0452 – that will be use to pay pathologists for their professional work in interpreting results.
CMS announced its decision in the final physician fee schedule rule, released Nov. 1. The agency said after reviewing comments, it believes “that the molecular pathology CPT codes describe clinical diagnostic laboratory tests that should be paid under the CLFS because these services do not ordinarily require interpretation by a physician to produce a meaningful result.”
CMS has not yet released its final CLFS for 2013 but is expected to any day now. The agency previously had indicated that it will use gap-filling methodology to price the tests. Under the gap-fill method, local Medicare contractors set the payment rate based on local pricing patterns.
While the agency said it does not believe molecular pathology tests are ordinarily performed by physicians, it acknowledge that in some case a physician interpretation of a molecular pathology test may be medically necessary. “In order to make PFS payment for that interpretation, on an interim basis for CY 2013, we have created HCPCS G-code G0452 (molecular pathology procedure; physician interpretation and report) to describe medically necessary interpretation and written report of a molecular pathology test, above and beyond the report of laboratory results.” For this code, CMS is assigning a work RVU of 0.37 and 5 minutes of pre-service time, 10 minutes of intra-service time, and 5 minutes of post-service time.
Physicians can also continue to receive payment for the current clinical pathology consultation CPT codes 80500 and 80502 if the pathology consultation service relating to a molecular pathology test meets the definition of those codes.