Compliance Corner

My pathologists believe that the tests listed on the Medicare Clinical Laboratory Fee Schedule that also allow for a professional component (PC) to be billed in certain circumstances can be billed every time as long as the required criteria are met. Is that a correct interpretation?

Yes and no. The three criteria that must be met are as follows:

  1. The interpretation must be specifically ordered by the treating physician;
  2. The pathologist must document the interpretive findings in the report for the test; and
  3. The interpretation must require the exercise of medical judgment by the pathologist.

Technically speaking, as long as these criteria are met, the pathologist can bill for the PC by appending a 26 modifier to the code for the technical part of the test and billing it on a separate line on the claim. However, caution should be exercised if your lab bills this every time in light of Medicare’s use of data mining techniques to scrutinize billing practices. If your lab’s claims for the PC are significantly higher in number than other similar labs’, it may find itself under scrutiny by a Medicare audit contractor and asked to provide documentation that the criteria were actually met.

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