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Clinical pathology - Professional BIlling Component

Posted Feb 18 2010 5:31pm

The issue is largely legal but I advise that the prfessional component should be considered medically necessary if properly billed with teh modifier -26.

The professional component of clinical pathology services by pathologists involves the use of medical judgment and constitutes the practice of medicine. Although there is no face-to-face interaction with a patient, these services include quality review adn the administrative component of directing a laboratory. Pathologists often bill private insurers for these services and the hopital bills for the techincal components seprately. The Medicare program provides for reimbursement for professional component of clini-cal pathology services to Medicare beneficiaries through Medicare Part A DRG pay-ments to hospitals, rather than through Medicare Part B payments directly to the pathologists.

For non-federal program (commercial carriers) covered patients, pathologists may bill for the same services by adding modifier -26, professional component, to the CPT codes of most clinical laboratory tests (i.e. CBC, Chemistry Profiles, TSH, etc). This is different than a Clinical Pathology Consultation (80500, 80502), which requires a written report in response to a request for the consultation by an attending physician].

This practice has been in effect for many years in Texas, California, Illinois and Florida, and pathologists from other states have been rapidly adopting it. Although its validity and legality have been challenged by commercial carriers and other entities several times, it has successfully been defended by several State Pathology Societies and is fully endorsed by the College of American Pathologists and the American Pathology Foundation. However, there have been court rulings, specifically in Florida, against this practice. In other jurisdictions, the courts have upheld the right of pathologists to bill eitehr the insurers or the patients.

Liston L: Dispelling the Myths - Billing for the Professional Component of Clinical Pathology, Laboratory Medicine, February 27, 2004

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