©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided by Coventry ® Illinois Medical Bill Reviewer Training Program Unit 1:Professional Services Module 5: Pathology and Laboratory Services

Illinois Regulation Training – Path & Lab 2 Overview Hello, in this module, you will learn about Pathology and Laboratory services and guidelines. Pathology and Laboratory Guidelines Types of Pathology Services Reimbursement per IL Medical Fee Schedule Well start by discussing the general guidelines, then move on to the different types of pathology services.

Illinois Regulation Training – Path & Lab 3 Pathology Guidelines Pathology is the study of the nature and cause of disease, which involves changes in structure and function. The Fee Schedule Pathology and Laboratory section ranges from A pathologist is trained to examine tissues, cells, and specimens of body fluids for evidence of disease.

Illinois Regulation Training – Path & Lab 4 Pathology Guidelines Compared to coding for anesthesia and surgical services, coding for pathology services is relatively simple. Pathology services: Are fully automated. Rarely need modifiers. Are not subject to multiple cascades. Subject to very few special rules.

Illinois Regulation Training – Path & Lab 5 Types of Service There are three categories of maximum medical reimbursement for pathology and laboratory services, such as... Professional Component Technical Component Lets take a look… Total Component

Illinois Regulation Training – Path & Lab 6 Professional Components There are certain pathology and laboratory codes that are for physician, or professional, services only. Professional Component Professional services include: Examining a patient. Conducting or supervising a procedure. Interpreting and documenting, in a written report, the examination & consultation with the referring physician. Designated by modifier 26

Illinois Regulation Training – Path & Lab 7 Professional Components When a charge is submitted for a physicians interpretation of a test or procedure, or other professional services related to that test or procedure, as designated by modifier 26, the maximum medical reimbursement will be that listed in the PC AMOUNT column of the fee schedule. Documenting interpretation of test and procedures is an integral part of the professional component.

Illinois Regulation Training – Path & Lab 8 Technical Component The technical component of service includes all other charges not related to the value of the physicians services. Technical Component Technical services include: Personnel (i.e. technicians) Space, equipment, and other facilities. Designated by modifier TC as listed in HCPCS Level II

Illinois Regulation Training – Path & Lab 9 Technical Component When a charge is submitted for only the technical component, as designated by modifier TC, the maximum medical reimbursement will be that listed in the TC AMOUNT column. Technical services are generally facility related.

Illinois Regulation Training – Path & Lab 10 Global Service The majority of pathology and laboratory procedures include both a professional and technical component, which constitutes a global service. For instance, a procedure is considered a global service when the same provider performs both the professional and technical components.

Illinois Regulation Training – Path & Lab 11 Global Components When a charge is submitted by one physician who provides both the technical and professional components of a pathology or laboratory, designated with no modifier, the maximum medical reimbursement will the amount listed in the TOTAL column. Remember, when there is not an established fee schedule allowable for the professional, technical or global component, service are paid at 76% of billed charge.

Illinois Regulation Training – Path & Lab 12 Summary Pathology and Laboratory: Professional Component. Service provided by physician – modifier 26 Pathology and Laboratory: Technical Component. Service provided by the facility – modifier TC Pathology and Laboratory: Global Component Physician preformed both PC & TC service – no modifier Good Job! Youre a Star.