Wiki Laboratory Place of Service

[msmythe]

I previously worked for an independent lab, was laid off, and have recently been thrown into the world of hospital laboratory billing. Which I am learning is much different from an independent lab.

There is the hospital lab that bills clinical charges and a pathology lab group that bills the professional charges. The pathology lab association to the hospital lab is unknown to me.
Question 1: Does the pathology lab association to the hospital effect place of service?

Recently the pathology lab has been billing on a 1500 form CPT 84165 with a 26 modifier and 86334 with a 26 modifier under place of service 11 due to the patient was drawn at a physicians office. Medicare is denying.
Question 2: Is place of service 11 appropriate in this situation?

CPT 84165 is also getting billed under the hospital lab globally on a UB form.
Question 3: Is it appropriate to be billing 84165 globally and with a 26 modifier? If you are familiar with Pagets they say you can, but to me it only sounds appropriate in certain situations.

Any help is appreciated. I have been in the lab industry for over 10 years, but hospital billing makes me feel like I am drowning!

 

[SharonCollachi]

The technical work was not done at the physicians office. The technical work was done after the specimen arrived at the lab, so you wouldn't use the POS 11. The only person who might do that is the physician who obtained the specimen in his office.

You are saying "pathology lab", but you are referring to the Pathology Group, correct? The physicians doing the professional work, and the Hospital Lab is where the work is done, the technical work.

 

[thomas7331]

There is the hospital lab that bills clinical charges and a pathology lab group that bills the professional charges. The pathology lab association to the hospital lab is unknown to me.
Question 1: Does the pathology lab association to the hospital effect place of service?

No, it should not make a difference. The physicians are only billing a professional service/interpretation and place of service billed by the physicians would reflect the location where that interpretation was done, unless your payer requires you to use the location of the patient rather than the physician for this specific type of service.

Recently the pathology lab has been billing on a 1500 form CPT 84165 with a 26 modifier and 86334 with a 26 modifier under place of service 11 due to the patient was drawn at a physicians office. Medicare is denying.
Question 2: Is place of service 11 appropriate in this situation?

It would not be appropriate to use the place of service where the lab was drawn because what is being billed is the interpretation, not the draw. But that place of service may be appropriate if those interpretations are being done in the physicians' own office. However, with a modifier 26 billed, it will not change the reimbursement in any way. Why is Medicare denying this - what is the denial reason? A denial may or may not have anything to do with the coding or place of service.

CPT 84165 is also getting billed under the hospital lab globally on a UB form.
Question 3: Is it appropriate to be billing 84165 globally and with a 26 modifier? If you are familiar with Pagets they say you can, but to me it only sounds appropriate in certain situations.

UB claims are not 'global' bills. Since only facilities use UB forms, it is presumed that any CPT/HCPCS codes billed are technical charges and hospitals are not required to append a TC modifier to these. (The rare exception is that some payers may allow or require hospitals to bill professional services on the UB, but those services would appear under different revenue code, e.g. 980-989, than the lab's technical charges which are billed with revenue codes 300-319.)

I'm not familiar with 84165 specifically, but it is listed on the Medicare physician fee schedule as having an assigned fee when billed with this modifier, which would indicate to me that there are situations where that would be appropriate.