Understanding Pathology Billing

Pathology billing is exceedingly complex, as this article will examine. According to the American College of Pathologists, the fact that private insurance companies often deny bills for clinical pathology’s professional component is one of the greatest difficulties that pathologists face today—and one that directly impacts the cash flow of their practices. This fact underscores why it is it so important for practices to understand the intricacies of pathology billing.

Let’s discuss how 1) how to bill for pathology services as an individual practitioner, 2) how to bill clinical pathology billing in laboratories, and 3) how to bill surgical pathology. Finally, we’ll assess when it might be wise to ask for the help of an accomplished professional third-party vendor of pathology billing services like Medusind.

How to bill for pathology services

To properly bill for pathology services as an individual provider, pathologists must use correct CPT codes, ICD-10-CM codes, and modifiers. Documentation is also essential to support your pathology billing. Here is more information so that you can get an expanded understanding of these issues:

• CPT codes

Current Procedural Terminology (CPT) codes identify a medical procedure or service. They are used for billing, reporting, and other administrative tasks. Pathologists should always use the CPT code that best describes the service they provided.

CPT codes for basic surgical pathology services range between 88300 and 88309. These codes are based on the specimen source and the specimen type. Medicare takes into consideration the amount of physician work, practice expense, and malpractice insurance expense when determining payment for a CPT code. 

For pathology practitioners, billing for a CPT code can be divided into the professional component (PC), which covers a physician’s professional service, and the technical component (TC), which covers laboratory work. When the professional component is added the technical component, the sum is known as the global fee.

Here are some examples of pathology CPT codes:

• A nonneoplastic appendix specimen: 88304

• A surgical pathology gross and microscopic examination: 88305
• Gastric biopsy: 88305, level IV surgical pathology, gross and microscopic examination

• Professional evaluation of a non-neoplastic colon segmental resection: 88307

• A colon resection for cancer: 88309

• If you use the unlisted molecular pathology code 81479, you must specify the gene being tested.

ICD-10-CM codes

ICD-10-CM stands for the International Classification of Diseases, Tenth Revision, Clinical Modification, a system that codes and classifies medical diagnoses. ICD-10-CM is based on ICD-10, the system used to code and classify mortality data from death certificates.

Pathologists must always use the ICD-10-CM code that supports their diagnosis. For example, K29.50 is the code for gastritis-related ailments. 

Modifiers

Regarding modifiers, pathologists are required to use these modifiers:

• Modifier 26 is used to bill for the professional component of a service (the pathologist’s work). 
• Modifier TC is used to bill for the technical component of a service (lab work). 
• Modifier 91 indicates that a test was performed more than once on the same day. 

In clinical pathology, receiving professional component payments are a major challenge for pathologists. While many private insurance companies incorrectly assert that Medicare fails to cover professional component services, Medicare does so under Medicare Part A for Hospital Insurance, according to the College of American Pathologists.

Documentation 

To ensure accurate reimbursement, pathologists are urged to carefully record and report all documentation in a patient’s medical record. Pathologists must include the patient’s name, dates of service, and the physician’s signature. Documentation must support the use of the selected CPT and ICD-10-CM codes.

Clinical pathology billing in laboratories

To bill for clinical pathology services in a laboratory, pathologists must use the appropriate CPT codes based on the specific test performed.

If pathologists are billing only for the professional component (physician interpretation), they must include the modifier 26. Bills must always be accompanied by accurate patient information, referring physician details, and proper coding for the specimen type and complexity of the test, following guidelines set by the College of American Pathologists and Medicare regulations.

If pathologists are billing for the technical component (lab work itself), they must employ the TC modifier when billing separately. 

Here are additional facts to consider when billing for clinical pathology.

• CPT Code

Pathologists must draw upon the correct CPT codes from the 88300 series for surgical pathology services, depending on the specimen type and complexity of analysis. 

• Modifier 26 (PC)

When pathologists are billing for the physician interpretation of the test results (professional component), they must always include the 26 modifier on the claim. 

• Modifier TC

When billing for the technical component (laboratory work) separately, pathologists should use the TC modifier. 

• Patient Information

The record of patient demographics must be accurate, including insurance details and referring physician information. 

• Specimen Type and Coding

Pathologists must accurately code the specimen type and any special handling required for the test. 

• Billing Compliance

Pathologists must strictly follow Medicare and commercial payer guidelines for billing clinical pathology services. 

Other important lab pathology billing considerations include:

• Laboratory Certification: pathologists must confirm that the laboratory is certified by the relevant regulatory bodies such as Clinical Laboratory Improvement Amendments (CLIA) to perform the requested tests. 
• Prior Authorization: For certain tests, the insurance company may require prior authorization to ensure payment.
• Billing Disputes: Pathologists should regularly review their billing reports and address any claim denials promptly. 

Surgical pathology billing

Surgical pathology billing relies on Current Procedural Terminology codes in the 88300–88399 range. These codes are based on the type and source of the specimen and the level of physician effort required. 

Steps for surgical pathology billing:

1. Determine the correct CPT code for the procedure.
2. Use modifiers to indicate multiple specimens, procedures, or diagnoses.
3. Document thoroughly.

CPT codes for surgical pathology:

• 88300: Gross examination only
• 88302: Gross and microscopic examination
• 88304: Level III surgical pathology
• 88305: Level IV surgical pathology
• 88307: Level V surgical pathology
• 88313: Special stain including interpretation and report

Pathologists can consult the CPT code book and the American Academy of Professional Coders (AAPC) CPT code hierarchy page to identify the correct code. 

Modifiers 

• 26: Used when billing for the professional component only
• TC: Used when billing for the technical component only
• 90: Used for certain CPT codes