Clinical laboratory tests or examinations are billed using different methods although the method used depends on the contractual or other type of mutual agreement between the facility and the physician and will apply to both inpatient and outpatient services, the principal determinant will be the provisions of the contract the facility has with the Medical program. Those facilities that are not under contract to Medical may make an arrangement with the Physician that is mutually agreeable within the policy guidelines.
Pathology Billing Methods:
1 Split Billable: Split-billable services is used when billing for both the professional and technical service components, a modifier is neither required nor allowed. When billing for only the professional component, use modifier 26. When billing for only the technical component, use modifier TC.
- Physician Billing – Physician bills for both the professional and technical components using one line without a modifier. The physician subsequently reimburses the facility for the technical component according to their mutual agreements.
- Facility Billing – Facility bills for both the technical and professional components using one line without a modifier. The facility reimburses the pathologist/pathology group for the professional component per their mutual agreements.
- Non-Split Billable Services: These codes are not separately reimbursable to different providers for a professional or technical component. Only one provider may bill for these codes. These codes must not be submitted with modifier 26, TC or 99, and do not require a modifier.
Split Billing Restrictions:
Ø Surgeons, internists, family physicians, podiatrists and other treating physicians who routinely review pathology results as an integral part of their reimbursed patient care services are not entitled to an additional reimbursement of a professional component for that review.
Ø This service, like other diagnostic data evaluation, is covered by the reimbursement for office visit and treatment.
Clinical Laboratory improvement Amendments (CLIA) Certification & Billing:
Ø CLIA requires all facilities that perform even one test, including waived tests, on “materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings,” to meet certain federal requirements.
Ø If a facility performs tests for these purposes, it is considered a laboratory under CLIA and must apply and obtain a certificate from the CLIA program that corresponds to the complexity of tests performed.
Ø Waived tests are those tests that have been determined to be so simple that if performed incorrectly will pose no risk of harm.
Ø The laboratory must comply with CLIA registration and certificate requirements and follow the manufacturer’s instructions for test performance
Certificate of Provider Performed Microscopy (PPM) Procedures
Ø Issued to a laboratory in which a physician, midlevel practitioner or dentist performs specific microscopy procedures during the course of a patient’s visit.
Ø A limited list of microscopy procedures is included under this certificate type and these are categorized as moderate complexity.
The use of modifiers with the procedure codes directs the claims adjudication system to reimburse the correct percentage for the component billed
Modifier 90: Used when service is performed by an outside laboratory but billed by another provider. Only specified providers may use this modifier.
Modifier 99: Used when two or more modifiers are necessary to define the procedure, And Modifier 99 must not be billed in conjunction with modifier 26 and/or modifier TC. The claim will be denied.
Modifier 33: Claims billed using Modifier 33 are not subject to specific ICD 10 Inclusion and or exclusion criteria. Use of Modifier 33 indicates service was provided in accordance with a US Preventive service and task force A and B Recommendation.
Modifier 26: Providers are not reimbursed for the professional component (modifier 26) of pathology claims billed with an Evaluation and Management (E&M) procedure performed by the same provider on the same date of service.
POS for Pathology Billing:
- If the physician bills Lab services performed in his / her office the POS code for Office is reported
- If the physician bills for a Lab test furnished by another physician who maintains a lab in his / her office, the code for other place of service is reported
- If the physician bills for a Lab test furnished by independent lab, the code for independent laboratory is reported.
- If an independent lab bills the place where the sample was taken is reported. An independent laboratory taking a sample in its laboratory shows 81 as POS
- If an independent lab bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it reports the code for the inpatient or outpatient Hospital respectively.