Policy Statements
Billing for the Professional Component of Clinical
Pathology
The Professional Component of Clinical Pathology accounts
for the Medical Directorship and Supervision of the Clinical
Laboratory, to assure for the timeliness, reliability, and
usefulness of test results, among many other
responsibilities, as outlined in CAP and CLIA’88 standards.
As you are probably experiencing, the test menu and required
knowledge in Laboratory Medicine has been rapidly expanding
and growing more complex thanks to constant technological
advances, especially in the areas of coagulation,
immunochemistry, molecular pathology and genetics. Never
before have Pathologists had a more crucial role in becoming
instrumental for the proper ordering and interpretation of
these tests by attending physicians.
Since 1983, Pathologists have been
reimbursed for these medical services through “Part A”, a
pass-down compensation by Hospitals to Pathology groups for
federal program (Medicare) covered patients (note: before
1983, the reimbursement was through “Part B”).
For non-federal program (commercial
carriers) covered patients, Pathologists may bill for the
same services by adding modifier -26, professional
component, to the CPT codes of most clinical laboratory
tests (i.e. CBC, Chemistry Profiles, TSH, etc). [Please note
that Professional Component of Clinical Pathology is
distinct from a Clinical Pathology Consultation (80500,
80502), which requires a written report in response to a
request for the consultation by an attending physician].
This practice has been in effect for many
years in Texas, California, Illinois and Florida, and
pathologists from other states have been rapidly adopting
it. Although its validity and legality have been challenged
by commercial carriers and other entities several times, it
has successfully been defended by several State Pathology
Societies and is fully endorsed by the College of American
Pathologists and the American Pathology Foundation.
Although it is your right, is also worth
noting that engaging in this practice carries significant
responsibilities from the Pathologists, requiring an active
involvement in the Clinical Laboratory as physicians. I
would strongly recommend reading and following the “Ten
Commandments of professional component billing”, by Jack
Bierig, esq., listed on the CAP’s website.
Multiple steps are required before
successfully implementing professional component billing.
First, gathering all educational material available for your
group, hospital administration, patients and commercial
payors; second, doing a feasibility study and financial
projection to determine if the endeavor is worth pursuing,
and third, but vital, obtaining the hospital’s approval for
the group to engage in it. The latter will require a
significant amount of education of the Pathologist’s role in
the Clinical Laboratory and the history of Professional
Component of Clinical Pathology, securing a mechanism to
minimize negative public relations for the hospital, and
perhaps even securing the services of a law firm
specializing in this matter. After those have been
accomplished, then follow with amending your contract to
reflect such approval, amending the patients’ registration
form to create a signed written consent, contracting a
capable and reputable billing company (considerable human
and technological resources are required), developing a
reasonable fee schedule and finally undergoing a process of
gradual implementation and active monitoring.
Success will depend on your degree of
involvement in the Clinical Laboratory, dedication to this
process, experience and resources of your billing company
and the hospital’s payor mix.
Edwin Leschhorn, M.D.
References:
From the College of American Pathologists website (cap.org):
The Ten Commandments of professional
component billing, by Jack R. Bierig, esq., March 2003
Florida squeeze: Florida court ruling
threatens professional component billing, by Jack R. Bierig,
esq., December 2002
PC Billing Information Package, December
2007
Check, please—getting paid for your work,
by Karen Titus, December 2005
Let’s learn from each other about CP pay,
by Mary Kass, MD, May 2005
Information Package DGP130, Professional
Component Billing
http://www.cap.org/apps/docs/statline/pdf/
palmetto_case_results.pdf
http://www.cap.org/apps/docs/statline/pdf/palmetto.pdf
http://www.cap.org/apps/docs/statline/pdf/
health_options.pdf
http://www.cap.org/apps/docs/statline/pdf/
policy__pathologist_professional_component_billing.pdf
CPT Assistant, Volume 9, Issue 5, May 1999
CPT Assistant, Volume 15, Issue 8, August 2005
Other websites:
http://www.calpath.org/clinical.htm
http://www.ilsocpath.org/legislative/clinicalpath.pdf
http://www.ilsocpath.org/legislative/procomponent.asp
http://www.ilsocpath.org/legislative/critical.asp
http://www.apcprods.org/mtg/2006/Thurs AM/PerSe ppt-
Colorado Springs.ppt
Journals:
Liston L: Dispelling the Myths - Billing
for the Professional Component of Clinical Pathology,
Laboratory Medicine, February 27, 2004
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