1. ©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided by Coventry Health Care® California Medical Bill Reviewer Re-Certification Unit 2: Official Medical Fee Schedule Module 7: Pathology & Laboratory

2. CA Regulations Training – Path & LabMarch 2010 Pathology and Laboratory Guidelines Types of Pathology Services Reimbursement per the Medicare Clinical Diagnostic Laboratory Fee Schedule Review of Diagnostic Tests Overview Hi! In this module, you will learn about pathology and laboratory services and how they are reimbursed. Well start by discussing some general guidelines as well as the different types of pathology services. Pathology and Laboratory Guidelines Types of Pathology Services

3. CA Regulations Training – Path & LabMarch 2010 Pathology Guidelines Pathology is the study of the nature and cause of disease, which involves changes in structure and function. A pathologist is trained to examine tissues, cells, and specimens of body fluids for evidence of disease. The OMFS Pathology and Laboratory section ranges from 80002-89399.

4. CA Regulations Training – Path & LabMarch 2010 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 cascade. Subject to very few special rules.

5. CA Regulations Training – Path & LabMarch 2010 Types of Service Much like radiology, there are two different components of pathology and laboratory services. Professional ComponentTechnical Component Lets take a look…

6. CA Regulations Training – Path & LabMarch 2010 Professional Components There are certain pathology and laboratory codes that are for physician, or professional, services only. No technical component is applicable to these codes. These codes include: 80500, 80502: Consultation 85060-85102: Bone marrow biopsy 86077-86079: Blood bank physician services 87164: Dark field examination 88000-88399: Anatomic pathology including autopsies, cytopathology, and surgical pathology

7. CA Regulations Training – Path & LabMarch 2010 Professional Components If you are thinking that professional components of pathology and laboratory services are indicated with Modifier –26, you are right! Modifier -26 applies to the professional components of both radiology and pathology and laboratory services. -26 Professional Component: This modifier indicates when the professional, or physicians component, of the procedure is reported separately from the technical component.

8. CA Regulations Training – Path & LabMarch 2010 Technical Components Under some circumstances, a bill may be submitted specifically for the technical component of a procedure. Again, in this instance, Modifier –27 is added to the bill. -27 Technical Component: This modifier indicates when the technical component of the procedure is reported separately from the professional component.

9. CA Regulations Training – Path & LabMarch 2010 Technical Components Codes corresponding to technical components shall be reimbursed according to CCR 9789.50. 1. Conveyance and handling fees are no longer reimbursed. The system is automated to deny these charges. Conveyance and handling fees are represented by codes: 99000 99001 99017 99019 99020 99021 99026 99027

10. CA Regulations Training – Path & LabMarch 2010 Technical Components 2. Effective for services after January 1, 2004: The Clinical Diagnostic Laboratory Fee Schedule for Medicare is the basis for laboratory services in California. The codes are paid 120% of the Medicare reimbursement. The Medicare Clinical Diagnostic Laboratory Fee Schedule is updated annually with new codes and pricing. The maximum reasonable fees for pathology and laboratory services shall not exceed 120% of the rate for the same procedure code in the Medicare Clinical Diagnostic Laboratory Fee Schedule.

11. CA Regulations Training – Path & LabMarch 2010 Technical Components 3. For any pathology and laboratory service not covered by a Medicare payment system, the maximum reasonable fee paid shall not exceed the fee specified in the OMFS 2003. 4. Although the appropriate laboratory pricing is automated in the system, if verification or manual pricing is necessary, the table can be accessed online in the file 06CLAB.ZIP at the following website: http://www.cms.hhs.gov/ClinicalLabFeeSched/02_clinlab. asp#TopOfPage

12. CA Regulations Training – Path & LabMarch 2010 Other Reimbursement Guidelines You might be interested to know that multi-channel bundling is no longer used in California. Furthermore, you should be aware that all pathology CPT codes that are accepted in the Medicare Schedule are accepted in California, whether or not they are in the Official Medical Fee Schedule.

13. CA Regulations Training – Path & LabMarch 2010 Review of Diagnostic Services As you know, physicians typically review laboratory test results. When the treating physician reviews the results of laboratory tests in conjunction with any E & M service, no separate charge is warranted. Do you know why a separate charge is not warranted in this instance? Thats right! It is not included because the review of diagnostic tests is included in Evaluation and Management codes.

14. CA Regulations Training – Path & LabMarch 2010 Summary Pathology and Laboratory: Guidelines and Services. Medicare Clinical Diagnostic Laboratory Fee Schedule. How reviews of diagnostic test results are reimbursed.