California Medical Bill Reviewer Re-Certification

1. California Medical Bill Reviewer Re-Certification Unit 2: Official Medical Fee Schedule Module 7: Pathology & Laboratory

2. Overview Hi! In this module, you will learn about pathology and laboratory services and how they are reimbursed. We’ll start by discussing some general guidelines as well as the different types of pathology services. • Pathology and Laboratory Guidelines • Types of Pathology Services • Pathology and Laboratory Guidelines • Types of Pathology Services • Reimbursement per the Medicare Clinical Diagnostic Laboratory Fee Schedule • Review of Diagnostic Tests

3. Pathology is the study of the nature and cause of disease, which involves changes in structure and function. Pathology Guidelines A pathologist is trained to examine tissues, cells, and specimens of body fluids for evidence of disease. The OMFS Pathology and Laboratory section ranges from 80002-89399.

4. Compared to coding for anesthesia and surgical services, coding for pathology services is relatively simple. Pathology Guidelines Pathology services: • Are fully automated. • Rarely need modifiers. • Are not subject to multiple cascade. • Subject to very few special rules.

5. Types of Service • Much like radiology, there are two different components of pathology and laboratory services. Professional Component Technical Component Let’s take a look…

6. There are certain pathology and laboratory codes that are for physician, or professional,services only. No technical component is applicable to these codes. Professional Components These codes include: • 80500, 80502: Consultation • 85060-85102: Bone marrow biopsy • 86077-86079: Blood bank physician services • 87164: Dark field examination • 88000-88399: Anatomic pathology including autopsies, cytopathology, and surgical pathology

7. If you are thinking that professional components of pathology and laboratory services are indicated with Modifier –26, you are right! Modifier -26 applies to the professional components of both radiology and pathology and laboratory services. Professional Components -26 Professional Component: This modifier indicates when the professional, or physician’s component, of the procedure is reported separately from the technical component.

8. Under some circumstances, a bill may be submitted specifically for the technical component of a procedure. Again, in this instance, Modifier –27 is added to the bill. Technical Components -27 Technical Component: This modifier indicates when the technical component of the procedure is reported separately from the professional component.

9. Technical Components • Codes corresponding to technical components shall be reimbursed according to CCR 9789.50. 1. Conveyance and handling fees are no longer reimbursed. Conveyance and handling fees are represented by codes: • 99000 • 99001 • 99017 • 99019 • 99020 • 99021 • 99026 • 99027 The system is automated to deny these charges.

10. Technical Components 2. Effective for services after January 1, 2004: The Medicare Clinical Diagnostic Laboratory Fee Schedule is updated annually with new codes and pricing. The maximum reasonable fees for pathology and laboratory services shall not exceed 120% of the rate for the same procedure code in the Medicare Clinical Diagnostic Laboratory Fee Schedule. The Clinical Diagnostic Laboratory Fee Schedule for Medicare is the basis for laboratory services in California. The codes are paid 120% of the Medicare reimbursement.

11. Technical Components 3. For any pathology and laboratory service not covered by a Medicare payment system, the maximum reasonable fee paid shall not exceed the fee specified in the OMFS 2003. 4. Although the appropriate laboratory pricing is automated in the system, if verification or manual pricing is necessary, the table can be accessed online in the file 06CLAB.ZIP at the following website: http://www.cms.hhs.gov/ClinicalLabFeeSched/02_clinlab.asp#TopOfPage

12. You might be interested to know that multi-channel bundling is no longer used in California. Furthermore, you should be aware that all pathology CPT codes that are accepted in the Medicare Schedule are accepted in California, whether or not they are in the Official Medical Fee Schedule. Other Reimbursement Guidelines

13. As you know, physicians typically review laboratory test results. When the treating physician reviews the results of laboratory tests in conjunction with any E & M service, no separate charge is warranted. Review of Diagnostic Services Do you know why a separate charge is not warranted in this instance? That’s right! It is not included because the review of diagnostic tests is included in Evaluation and Management codes.

14. Pathology and Laboratory: Guidelines and Services. Medicare Clinical Diagnostic Laboratory Fee Schedule. How reviews of diagnostic test results are reimbursed. Summary