CAM 472

Laboratory/Pathology Services

Category:Laboratory   Last Reviewed:August 2019
Department(s):Medical Affairs   Next Review:August 2020
Original Date:April 1997    

Description:
The purpose of this policy is to outline when it is appropriate to allow reimbursement for the physician component of certain clinical pathology services.  This policy also addresses the processing of automated laboratory tests.

Policy Statement:
Professional Clinical Laboratory
It has been customary to recognize the physician component of certain clinical pathology services for separate reimbursement when it is inappropriate for the physician to bill the global service because the technical component was rendered by a technician or another physician who performed the technical component of the service only.  The technical component represents the facility charge for administering a service: machinery, technicians and supplies required to perform the procedure.  The professional component represents the physician’s charge for direct involvement in performing or interpreting the procedure performed.  Examples of professional components that are appropriate for reimbursement would include:

  • Interpretation and report of a clinical pathology examination rendered by a physician who has no association with the laboratory that prepared the specimen. 

The factors necessary for the recognition of such services for reimbursement would include:

  • The interpretation and report must be necessary for the appropriate evaluation and treatment of the patient (medically necessary).
  • The interpretation and report must have been requested by the attending physician (a request for consultation).
  • The interpretation and report must be based on the physician’s personal evaluation of the pathological specimen or the specific laboratory findings.  The physician must provide a written report signed by the physician that documents the interpretation or opinion.

Professional components are not recognized for routine clinical pathology services when those services involve testing of clinical specimens by automated machinery when the machine generates the test result without the necessity for physician interpretations.

A professional component of a technical service can be recognized as appropriate for reimbursement under the following guidelines:

  • The interpretation of the result and a written report is medically necessary for the appropriate evaluation and treatment of the patient.
  • The interpretation and report has been requested by the attending physician.
  • The interpretation in the report is based on the physician’s personal evaluation of the pathological specimen or the specific technical findings.
  • The reporting physician creates a report that is specific to the individual patient’s technical findings and signs and dates that report.

A professional component is recognized for codes CMS designates as appropriate for a separate professional interpretation.  See the codes listed below:

83020

HEMOGLOBIN FRACTIONATION & QUANTITATION; ELECTROPHORESIS

84165

PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION

84166

PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF)

84181

PROTEIN; WESTERN BLOT, W/ INTERPRETATION & REPORT, BLOOD/OTHER BODY FLUID

84182

PROTEIN; WESTERN BLOT, W/ INTERPRETATION & REPORT, W/ IMMUNOLOGICAL PROBE, EACH

85060

BLOOD SMEAR, PERIPHERAL, INTERPRETATION, PHYSICIAN W/ WRITTEN REPORT

85390

FIBRINOLYSINS/COAGULOPATHY SCREEN, INTERPRETATION & REPORT

85576

PLATELET; AGGREGATION (IN VITRO), EACH AGENT

86153 

Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood); physician interpretation and report, when required

86255

FLUORESCENT NONINFECTIOUS AGENT ANTIBODY; SCREEN, EACH ANTIBODY

86256

FLUORESCENT NONINFECTIOUS AGENT ANTIBODY; TITER, EACH ANTIBODY

86320

IMMUNOELECTROPHORESIS; SERUM

86325

IMMUNOELECTROPHORESIS; OTHER FLUIDS W/ CONCENTRATION

86327

IMMUNOELECTROPHORESIS; CROSSED (2-DIMENSIONAL ASSAY)

86334

IMMUNOFIXATION ELECTROPHORESIS

86335

IMMUNOFIXATION ELECTROPHORESIS; OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF)

87164

DARK FIELD EXAM, ANY SOURCE; W/ COLLECTION

87207

SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, MICROSPORIDIA, TRYPANOSOMES, HERPES VIRUSES)

88104

CYTOPATHOLOGY EXCEPT CERVICAL/VAGINAL; SMEARS W/ INTERPRETATION

88106

CYTOPATHOLOGY, FLUIDS, WASHINGS OR BRUSHINGS, EXCEPT CERVICAL OR VAGINAL; SIMPLE FILTER METHOD WITH INTERPRETATION

88108

CYTOPATHOLOGY, CONCENTRATION TECHNIQUE, SMEARS & INTERPRETATION

88112

CYTOPATHOLOGY, SELECTIVE CELLULAR ENHANCEMENT TECHNIQUE WITH INTERPRETATION (EG, LIQUID BASED SLIDE PREPARATION METHOD), EXCEPT CERVICAL OR VAGINAL

88120 

CYTOPATHOLOGY, IN SITU HYBRIDIZATION (EG, FISH), URINARY TRACT SPECIMEN WITH MORPHOMETRIC ANALYSIS, 3-5 MOLECULAR PROBES, EACH SPECIMEN; MANUAL

88121 

CYTOPATHOLOGY, IN SITU HYBRIDIZATION (EG, FISH), URINARY TRACT SPECIMEN WITH MORPHOMETRIC ANALYSIS, 3-5 MOLECULAR PROBES, EACH SPECIMEN; USING COMPUTER-ASSISTED TECHNOLOGY

88125

CYTOPATHOLOGY, FORENSIC

88160

CYTOPATHOLOGY, OTHER SOURCE; SCREENING & INTERPRETATION

88161

CYTOPATHOLOGY, OTHER SOURCE; PREPARATION, SCREENING & INTERPRETATION

88162

CYTOPATHOLOGY, OTHER SOURCE; EXTENDED STUDY, > 5 SLIDES &/OR MULTIPLE STAINS

88172

CYTOPATHOLOGY, EVAL FINE NEEDLE ASPIRATE; IMMEDIATE CYTOHISTOLOGIC STUDY TO DETERMINE ACCURACY

88173

CYTOPATHOLOGY, EVAL FINE NEEDLE ASPIRATE;  INTERPRETATION & REPORT

88177 

CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE ASPIRATE; IMMEDIATE CYTOHISTOLOGIC STUDY TO DETERMINE ADEQUACY FOR DIAGNOSIS, EACH SEPARATE ADDITIONAL EVALUATION EPISODE, SAME SITE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

88182

FLOW CYTOMETRY, CELL CYCLE OR DNA ANALYSIS

88199

UNLISTED CYTOPATHOLOGY PROC

88300

LEVEL I - SURGICAL PATHOLOGY, GROSS EXAM ONLY

88302

LEVEL II - SURGICAL PATHOLOGY, GROSS & MICROSCOPIC EXAM

88304

LEVEL III - SURGICAL PATHOLOGY, GROSS & MICROSCOPIC EXAM

88305

LEVEL IV - SURGICAL PATHOLOGY, GROSS & MICROSCOPIC EXAM

88307

LEVEL V - SURGICAL PATHOLOGY, GROSS & MICROSCOPIC EXAM

88309

LEVEL VI - SURGICAL PATHOLOGY, GROSS & MICROSCOPIC EXAM

88311

DECALCIFICATION PROC

88312

SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE); GROUP I FOR MICROORGANISMS (EG, GRIDLEY, ACID FAST, METHENAMINE SILVER), EACH

88313

SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE); GROUP II, ALL OTHER (EG, IRON, TRICHROME), EXCEPT IMMUNOCYTOCHEMISTRY AND IMMUNOPEROXIDASE STAINS, EACH

88314

SPECIAL STAINS; HISTOCHEMICAL STAINING W/ FROZEN SECTION(S)

88319

DETERMINATIVE HISTOCHEMISTRY/CYTOCHEMISTRY, IDENTIFY ENZYME CONSTITUENTS, EACH

88323

CONSULTATION & REPORT, REFERRED MATL REQUIRING PREPARATION, SLIDES

88331

PATHOLOGY CONSULTATION DURING SURGERY; FIRST TISSUE BLOCK, W/ FROZEN SECTION(S), SINGLE SPECIMEN

88332

PATHOLOGY CONSULTATION DURING SURGERY; EACH ADD'L TISSUE BLOCK W/ FROZEN SECTION(S)

88333

PATHOLOGY CONSULTATION DURING SURGERY; CYTOLOGIC EXAMINATION (EG, TOUCH PREP, SQUASH PREP), INITIAL SITE

88334

PATHOLOGY CONSULTATION DURING SURGERY; CYTOLOGIC EXAMINATION (EG, TOUCH PREP, SQUASH PREP), EACH ADDITIONAL SITE

88341 

IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY, PER SPECIMEN; EACH ADDITIONAL SINGLE ANTIBODY STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE. 

88342

IMMUNOHISTOCHEMISTRY (INCLUDING TISSUE IMMUNOPEROXIDASE), EACH ANTIBODY

88344 

IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY, PER SPECIMEN; EACH MULTIPLEX ANTIBODY STAIN PROCEDURE 

88346

Immunofluorescence, per specimen; initial single antibody stain procedure

88348

ELECTRON MICROSCOPY; DX

88350 

Immunofluoroscence, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) 

88355

MORPHOMETRIC ANALYSIS; SKELETAL MUSCLE

88356

MORPHOMETRIC ANALYSIS; NERVE

88358

MORPHOMETRIC ANALYSIS; TUMOR (EG, DNA PLOIDY)

88360

MORPHOMETRIC ANALYSIS, TUMOR IMMUNOHISTOCHEMISTRY (EG, HER-2/NEU, ESTROGEN RECEPTOR/PROGESTERONE RECEPTOR), QUANTITATIVE OR SEMIQUANTITATIVE, EACH ANTIBODY; MANUAL

88361

MORPHOMETRIC ANALYSIS, TUMOR IMMUNOHISTOCHEMISTRY (EG, HER-2/NEU, ESTROGEN RECEPTOR/PROGESTERONE RECEPTOR), QUANTITATIVE OR SEMIQUANTITATIVE, EACH ANTIBODY; USING COMPUTER-ASSISTED TECHNOLOGY

88362

NERVE TEASING PREPARATIONS

88364 

IN SITU HYBRIDIZATION (EG, FISH), PER SPECIMEN; EACH ADDITIONAL SINGLE PROBE STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 

88365

TISSUE IN SITU HYBRIDIZATION, INTERPRETATION & REPORT

88366 

IN SITU HYBRIDIZATION (EG, FISH), PER SPECIMEN; EACH MULTIPLEX PROBE STAIN PROCEDURE 

88367

MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION (QUANTITATIVE OR SEMI-QUANTITATIVE) EACH PROBE; USING COMPUTER-ASSISTED TECHNOLOGY

88368

MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION (QUANTITATIVE OR SEMI-QUANTITATIVE) EACH PROBE; MANUAL

88369 

MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION (QUANTITATIVE OR SEMI-QUANTITATIVE), MANUAL, PER SPECIMEN; EACH ADDITIONAL SINGLE PROBE STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 

88371

PROTEIN ANALYSIS, TISSUE, WESTERN BLOT, W/ INTERPRETATION & REPORT

88372

PROTEIN ANALYSIS, TISSUE, WESTERN BLOT, W/ INTERPRETATION & REPORT; IMMUNOLOGICAL PROBE, EACH

88373 

MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION (QUANTITATIVE OR SEMI-QUANTITATIVE), USING COMPUTER-ASSISTED TECHNOLOGY, PER SPECIMEN; EACH ADDITIONAL SINGLE PROBE STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

88374

MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION (QUANTITATIVE OR SEMI-QUANTITATIVE), USING COMPUTER-ASSISTED TECHNOLOGY, PER SPECIMEN; EACH MULTIPLEX PROBE STAIN PROCEDURE 

88377 

MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION (QUANTITATIVE OR SEMI-QUANTITATIVE), MANUAL, PER SPECIMEN; EACH MULTIPLEX PROBE STAIN PROCEDURE 

88380

MICRODISSECTION (IE, SAMPLE PREPARATION OF MICROSCOPICALLY IDENTIFIED TARGET); LASER CAPTURE

88381

MICRODISSECTION (IE, SAMPLE PREPARATION OF MICROSCOPICALLY IDENTIFIED TARGET); MANUAL

88399

UNLISTED SURGICAL PATHOLOGY PROC

89060

CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANALYSIS, TISSUE OR ANY BODY FLUID (EXCEPT URINE)

Automated Multi Channel Chemistry Tests
Twenty-three common laboratory tests are classified  as "automated, multichannel chemistry tests." The automated test list is based on the 19 tests that could be performed on the original automated chemistry analyzers. GGT, triglycerides, CPK and iron were added later. The current list of automated tests includes:

Albumin, alkaline phosphatase, AST, ALT, direct and total bilirubin, BUN, carbon dioxide, calcium, cholesterol, chloride, CPK, creatinine, glucose,  glucose-6-phosphate dehydrogenase, GGT, LDH, phosphorus, potassium, total protein, sodium, triglycerides, uric acid and iron.

Regardless of the method used to perform the tests, whether by the automated or non-automated method, the allowance for the individual tests will be limited to the amount paid for the corresponding automated panel.  

Medicare Coordination of Laboratory Services of the State of South Carolina:
The Omnibus Budget Reconciliation Act clarifies the mandatory assignment provision, which applies to laboratory services performed in a physician’s office.  Assigned claims for clinical laboratory services are reimbursed at 100% of the approved amount with no coinsurance or deductible applied.

Physicians must accept assignment for clinical diagnostic laboratory services performed by the physician or under their supervision.  Medicare will deny any clinical laboratory charges filed by a non-participating physician on non-assigned claims as non-covered.

Non-participating physicians who render a clinical laboratory service and other office services on the same date may file two separate claims.  An example of this would be one accepting assignment for the clinical lab service and the other non-assigned claim for other services.  This is the only instance where Medicare accepts two different assignment intentions for the same date of service.

As assigned laboratory claims are reimbursed at 100% of the approved amount, there is no coordinated payment.  These charges should be submitted with a provider remittance and should be non-covered as paid in full by Medicare.

Claims that are submitted for coordination should always have an Explanation of Medicare Benefits or Provider Remittance attached.  If either of these items is missing, charges should be non-covered for lack of Medicare information.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

08/01/2019 

Annual review, no change to policy intent. 

08/07/2018 

Annual review, no change to policy intent. 

03/28/2018 

Interim review to remove codes that CMS no longer supports a 26 modifier with:80500, 80502, 85097, 85396, 86077, 8607886079, 86485, 86486, 86490, 86510, 86580,88141, 88187, 88188, 88291, 88299, 88321, 88325, 88329, 89049, 89220, 89230, 89240, G0124 and G0141. No other changes made. 

08/01/2017 

Interim review removing 88184, 88185 from the list of codes appropriate for a 26 modifier as they are technical component only by verbiage. No other changes. 

04/26/2017 

Updated category to Laboratory. No other changes. 

01/05/2017 

Annual review, no change to policy intent. 

01/11/2016 

Annual review, no change to intent of policy, updating verbiage for 88346, removing deleted code 88347 adding new code 88350.

09/01/2015 

Annual review, updated coding to maintain current coding. Also changed review date to January to allow for coding update at that time. 

09/11/2014 

Annual review, updated codes  listed to include new codes and remove deleted coding. No change to policy intent. Additional note, codes added and deleted were confirmed with Pam Herring utilizing CMS data.

04/17/2014

 Made Policy external. 

 


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